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Thursday, December 12, 2002

Session 4: What's Wrong with Enhancement:
Discussion of Paper

Prepared by Michael J. Sandel, D. Phil.

CHAIRMAN KASS: While we are coming back to order, let me simply make a comment to the council members, both with respect to the session that we have just finished, and the sessions this morning.

There are I know some of you, because you have spoken to me privately about this before, who are concerned about the connection between the kinds of conversations that we have had here as illuminating and interesting as they may be, to the charge to this council, and the to the questions of public policy, though I remind you that part of our task is to articulate the human and moral significance of these advances even before we say good, bad, or indifferent, or recommend things for the President or other people to do.

I was — and as often the case, although I am interested in the conversation, I am trying to take the temperature of the room, and especially when the lights are down, it is not always easy to see what is behind these genial facades.

This last topic, where — and especially the way that Dr. Diller presented it, it is perfectly clear that this is not a matter for which some simple government regulation has got some kind of answer.

The most that you are going to do is either do something about advertising or something about production. On the other hand, it does seem to be a topic of very rich — or at least at the center of some of the things about which we have been concerned at least in this part of our work.

And I will follow up with you after this meeting, but I would be interested to know what members think is the value of perhaps pursuing this topic in somewhat greater depth, and maybe to invite some additional conversations on it.

Partly because there has been some public attention to it, and partly because it is a way of calling attention to the kinds of dimensions of the uses of these technologies that are not simple — this is right or this is wrong, or pass a law, or set up a regulation.

And the question is whether this is something that we are equipped to do or equipped to do well, or whether you think that what we had this morning or this afternoon on this topic was somehow sufficient.

So please be thinking about it, and if you have opinions about that now, or during the course of this meeting, pass them on to me or to Dean. But this is an area where, as Bill made a comment to me at the break, that there is at least a large and influential constituency, namely the middle and upper-middle class, who have a horse in this race, and who have some kind of concern, and who have some kind of voice, which is not the case with respect to some of the other things that we have talked about.

So be thinking about it, and let us hear from you. The second announcement before we turn to the discussion of Michael Sandel's discussion paper is to say that a request has been made that council members, or at least some council members would like to have some feedback and reaction to our special visitors from the Center of Ritalin Prescription.

And I would like to invite any members of the council who would be free to simply, when we adjourn today, which will be about 5:30, to simply spend 15 or 20 minutes with these young people if you would like.

Those of us who want to sit around with them, we will do so, and the rest can move and prepare for our dinner. But we will do that in this room, and we will break briefly so that anybody who would like to leave can do so unobtrusively and without embarrassment.

But if you are — and again if some of you are willing to say, and we would be glad to hear — and not to be interrogated, but to hear your own thoughts about these matters. Thank you.

And with that, I would like to open the discussion of Michael Sandel's paper, entitled, "What is Wrong With Enhancement." As it indicates itself, it is an attempt to give voice to some of the disquiets that have been uttered in this room on several occasions as we have moved from the blood doping of athletics, to various mood, memory, and behavior altering drugs, to choosing sex of children tomorrow.

And we will hear from Francis Collins on the possibilities of genetic enhancement, and this is Michael's attempt to set aside on one hand the questions of safety and unfairness, and to try to talk some about the thing itself.

It is brief, and it is concise, and I think it should provoke an interesting discussion. And Michael has indicated that he has had his say, and would like the conversation to proceed.

There will be a return to this topic at the next meeting, wherein we hope to bring before you some of the staff prepared working chapters on the particular topics. And I have at least volunteered something on this topic myself.

So that we will have at least one more go on the general topic, but Michael has done us all a service by trying to focus at least his own thoughts and clarify some of the issues before us in this paper. And I simply would just open the meeting for its discussion.

Charles, you were neglected at the end, and you are one of the less than silent characters in the presentation of this. I don't know or don't want to put you on the spot, but if you have something to open with, that could get the ball rolling.

DR. KRAUTHAMMER: Let me just say that the last session I think was — we had been talking about enhancement in the abstract and often wondering why we are talking about it, and whether this is highly theoretical, abstract, and future oriented.

And I was struck by how the last session illustrated that we have a massive huge current case of mass enhancement, if you like, happening before our eyes. And this is as concrete a case as we could have.

And it seems to me that it might turn out to be the fulcrum of whatever general report or discussion that we have. I would certainly like to start with that, because it is such a striking case. And let me digress for a second from Michael's paper and refer to the last session. It seems to me that what we have heard from Dr. Diller and what I think is fairly clear is that there might be a very small number of cases of a real disorder or a disease, a very small number.

And that the rest is classic enhancement, and these are kids whose performance is enhanced by a drug that we know can do specific things, and happening on a mass scale, with the interesting good twist that it is being imposed on children.

So that it is a form of social control and sort of pedagogical pharmacology, or pharmacological pedagogy is more accurate. And it troubles me, and I think we ought to really maybe focus, at least if the staff is going to be preparing a paper on this, as to what is troubling about it, and whether or not apart from the question of regulating it, whether or not we can articulate what is wrong with it.

And I think that there is a lot wrong with it, and it might be the starting point in any discussion of enhancement. Now, that is just sort of to take off from what I had intended to say at the end of the last session.

I think that Michael's paper is really a wonderful summary of this question, and I think that he gets right to the basic issue. Safety is too easy a way to dismiss enhancement. It is a distraction.

Fairness is also not the real issue, because if you let everybody have the enhancing agent, then you have overcome the fairness issue. The real question is why does this disturb us or why does it bother us.

And I think that he has sort of given us the two basic answers. Agency and — well, diminished agency and hyper-agency. I tend to the first view because I think it is so simple and easy to understand, and intuitive, and then I will defer to Michael to try to convince us on the second, which I think is more subtle, and which is harder to grasp.

But I think the reason that we are disturbed about enhancing drugs or enhancing surgeries or enhancing genetic manipulations in the future is that it is the Rosie Ruiz of achievement.

It gets you there by a way that does not require your own effort, and is a way around effort, and application, and demonstrations of excellence. And it is simply — it is both cheating and cheap as I said at our discussion at lunch.

And it diminishes our humanity to do things that way. As I understand Michael's argument, that is one way to look at it, but there is a more subtle thing that is diminished by the use of enhancing agents, and that is — well, it is not diminished. Our humanity is diminished by the fact that we are sort of acting as super humans.

And creating where we shouldn't be creating, and determining where we shouldn't be determining. And that it is fundamentally an issue of hubris. I find that harder to grasp, and because it is less intuitive, if I could, I would defer to Michael to try to explain to us how that ought to be our chief concern about enhancement.

CHAIRMAN KASS: Janet.

DR. ROWLEY: Well, this is an area where I am totally out of my depth, and I did comment to Michael on what a marvelous piece of — of trying to describe the problem, and to actually point out its subtleties.

But let me take a totally different point of view, and if what one wants for global society is an enhancement of life overall in that society, then why is it wrong to help individuals, or let individuals help themselves to achieve greater things for that society.

CHAIRMAN KASS: Michael, do you want to collect or do you want to respond? Maybe it would be better to respond, rather than to treat this as a press conference and we will discuss issues. So why don't you — well, did you want to piggyback on that or go somewhere else perhaps?

PROF. BLACKBURN: I think this is a piggyback, and stop me if it is not, but it got me thinking about hubris, and I sort of see two kinds of aspects to hubris, and I wondered if you could clarify that.

One is the hubris where something is done and then because we didn't know enough about it, that we arrogantly thought that we did, and then we come to some catastrophe unintended, because we basically thought we knew more than we did.

And then the other is I think or what I sense as being the other meaning of hubris, which is just the arrogant period. You know, even if there were no unintended sequela that just the act of doing that.

And so perhaps you could in the course of you discussing these questions clarify how you feel about those two in your discussions. I liked your piece very much indeed, and that was a strong test of me having to read it, and having gotten off the plane, I read it last night, and I enjoyed it very much. So I enjoyed it under tough conditions.

DR. KRAUTHAMMER: If I could piggyback on the piggyback, and just sharpen the question. This is sort of a double-jump. It is just to say to Michael that if I understand your argument, it seems to be very broad and very sweeping, as a way of saying that by not accepting nature's gifts as is, and trying to either imitate or surpass them by some mechanism, we are acting in a hubristic way, and exercising a mastery that is somehow morally or humanly illegitimate.

And it would seem to me that the logical extension of that argument is that — and you sort of hint this in your last line — is to return to a 17th century vision, and a reenactment of nature that is sort of a questioning and undermining of the entire scientific enterprise, if not the whole biomedical enterprise, which is precisely to deny nature, and to overcome it, and to master it.

It seems to be a fairly radically conservative position, which I find rather in principle coming from you delightful. But I am not even sure that I would embrace it. So let me pose it that way.

CHAIRMAN KASS: I think rather than put more pigs on this back, let's let Michael respond, because he has got —

PROF. MEILAENDER: That is quite a metaphor, Leon.

PROF. SANDEL: Well, these are terrific questions, and I am not sure what the answers are, but let me try. To begin with, Charles' last question, first, and then to work back.

My suggestion is not the thoroughgoing quietistic conservative acceptance of nature that you suggest. I don't think that we should accept nature's givens or gifts as is.

That would be too quietistic. I am not one of those, though there are some who think that creation is complete, and that the work of creation should simply be an object of reverence and awe, but I don't accept that view.

And I think modern science, any science, would be wholly disabled by that view. I think that the view that I want to try to work out here is one that allows room for, and even imperatives for, human beings participating in repairing the given world.

So the given can't go without interrogation or question. The suggestion though by emphasizing the giftedness is a counter-weight to the willfulness that predominates in our culture, is really just an argument to accord weight to the given.

And to accord some respect to the given as we go about exercising our will and participating in repairing the given. And so to go to — and to try and develop this by working my way back across the questions that Elizabeth and Janet have raised, the hubris, it can't be hubristic to try to make things better, and this is also to Janet's question.

That would be too heavy a notion of hubris. It would be entirely disabling, not only of science, but of all sorts of human projects of moral and political, as well as scientific improvement.

What I am trying to — I am trying to develop some considerations that can combat our tendency, which is the opposite tendency, to ride roughshod over the given without interrogating it or appreciating it.

And so to the two senses of hubris that Elizabeth raised, I think I am for some version of the first, where the hubris consists in thinking we know what we are doing, but not fully understanding the consequences of what we are doing.

But it can be tricky to distinguish the first kind of hubris from the second, and one way of getting at this is to go back to the earlier discussion that we had, the Ritalin discussion, because in one way the knowledge is true knowledge. That if we give the child the Ritalin that it will have this effect on the child's behavior. So it is true knowledge, but when we get into the larger unintended consequences, not even putting aside some unintended consequences about incurring addiction down the road.

But let's say that it were not addictive and that there was no harm to this child. Still what we might miss would be precisely by riding roughshod over the given, by making this a widespread practice, we would diagnose it in cases where we would actually have, let's say, an accurate diagnosis that the kid was, or had, attention deficit disorder, or couldn't fit in that well, or was a nuisance in the classroom.

But — and here is where this goes back to Charles' first question. Here is where the mistake is not just that we are cheating and we are giving the kid an edge that doesn't come from the kid's own effort, and this also addresses Frank's construal of that position.

The real wrong it seems to me here is by not appreciating the given, we miss human qualities that at first glance may appear to be just a form of nuisance.

And here there are two cases that I would like to bring us back to; the Huck Finn case, and the young Paul McHugh case, where at first glance what we now appreciate as Paul's feistiness, then, looking quickly anyhow, was just a nuisance in the classroom let's say. I am imagining.

And so we wouldn't say when we prescribe Huck Finn or the young Paul McHugh the Ritalin, we wouldn't say what was quietistic and in what ways does mastery run wild, failing to appreciate the given.

Well, you might say the given is the scourge. It is this kid running around making trouble, and that might actually be true. But by not running roughshod over the given, and by interrogating it, and by inquiring into it, and by enlarging our moral imagination about the way this trait might if properly understood fit into a larger narrative of human possibilities, we might say, yes, we could cure the squirminess now and the misbehavior, but at a cost.

And not at a cost that later that he will become addicted. So here, Elizabeth, is where it is or we are getting it right in the narrow sense. The knowledge isn't false. It will cure the squirminess, but by attending to the given, we come ultimately to see the feistiness under another description as a gift, and not just a nuisance.

And so here is how it is not just quietistic. Here is where there is an interrogation of the given, and the interrogation, and how successful it is, will depend on the reach of our moral imagination may be competing narratives and descriptions of how this terribly troublesome kid might actually — that there might implicitly be some implicit human qualities that are worth apprising.

So it is not purely quietistic. We wouldn't always defer. We might do our best to figure out what is going on here and say, well, better that he should have the Ritalin.

There are some gifts that aren't transparent as gifts. That we might have to learn to love Paul's feistiness, but having learned, then we do see it as a gift; whereas, at first it really wasn't.

So the appreciation that I am arguing for here can very well be an acquired taste, but the moral project, the task of the moral imagination here, is to be open to the acquisition of acquired taste of that kind.

CHAIRMAN KASS: Did you want to comment to Janet, or just the comment —

PROF. SANDEL: Well, I thought I sort of had, and Janet will tell me if I hadn't. So this is not against improvement. This is not against improvement, but because I meant the example to show how by interrogating the given that we may appreciate it, but we may also decide that in some cases — well, still, we have to fix this.

And I am not saying that we should never fix things. Often we will come to the conclusion that what has been given is something that is in need of fixing it, of repairing. But maybe I didn't address fully what you were worried about.

DR. ROWLEY: Well, just the comment that your examples in the discussion really related to individuals and comparing individuals who — one has given a great deal of effort to achieve a very high level of performance, and another just does it effortlessly because they are very fortunate to have been born with it.

And then if you by giving a drug help one, compared to the other, doesn't that somehow taint what appears to be success on the part of the person, because it is not the person's achievement. It is the drug's achievement.

And I fully accept that, but I was just thinking that we have discussed it, and I would have to say that I was surprised, though we had this conversation some months ago, and again at the extent to which people are using various stimulants in the broader population, that looking at the other side of it, if you — if these help people to achieve more — and I think that this is a big if, because Dr. Diller said that in the long run the children taking Ritalin didn't do any better in performance than the children who didn't.

And so that says in the long run that it doesn't make any difference. But the contrary point that I was trying to say is if in fact some of these help people to achieve more or to be more creative in ways that advances societal goals, then should we look and not be quite so judgmental as we may appear to be?

CHAIRMAN KASS: Frank, go ahead, and then we have to go to Professor Sandel's presentation.

DR. FUKUYAMA: Well, I would like to answer exactly that point. I mean, I think that you have to have an unambiguous understanding of what it means to — you know, what is unambiguously an enhancement or an achievement, and I think that most people that say, well, why not, think that that is an unambiguous — you know, it is pretty unambiguous what makes a better human being.

You know, if it is somebody that achieves higher test scores, or has an higher IQ. But I think that a lot of the things that are possible now, and may be possible in the future, are very ambiguous.

For example, would it enhance a person to cure a child of any genetic predisposition for homosexuality. Is that an enhancement? Is the world better off — you know, is society better off if parents had that choice of preventing that particular disposition.

Is it better — you know, I have been involved in a variety of these kind of hypothetical things, but supposing that you could eliminate proclivities for hatred.

I mean, people would say, well, wouldn't the world be better off without hatred. Well, yes and no. If there are no hateful things in the world, then maybe the world would be better off if you didn't have this emotional response.

But if there are really hateful things, then maybe that is not such a good thing. The same thing with proclivities for violence and aggression. I mean, these are commonly thought of as targets of enhancement.

Wouldn't the world be better off if we had less of this, and I think in just the examples that we have had that I was astounded that there is this thing in the DSM called oppositional disorder, which I assume is something that Martin Luther and Rosa Parks had in spades, you know.

And if you have this drug that allows you to get over oppositional disorder, have you enhanced society, and are the goals of that enhancement so obvious.

And I just don't think they are. I mean, I think that is the fundamental problem. And I guess that is in a way what you are talking about with the — I mean, I guess trashing the given, I don't like that language, because it just sounds too conservative.

I just think that the problem is that what is given and what is an alternative to the given are morally laden terms, where people act as if it is obvious in which direction improvement lies.

And I think that is the fundamental issue here, and that in many cases it really is not. I mean I will stop there.

CHAIRMAN KASS: Bill May, and then Gil, and then Alfonso.

DR. MAY: I have a cluster of points. Your paper contrasts —

CHAIRMAN KASS: Bill, could you get closer to the mike, please.

DR. MAY: Your paper contrasts openness to nature's gift, and then on the other side willful control. There is a complication that part of the gift is the ability to control.

So part of the honoring of the gift, it might be slothful, inadequately to respond to challenges for control. So it would not be an active impiety to engage in controlling. It would be acting upon a portion of the gift.

Nevertheless, at the same time, all of our discussion of enhancement today is related to the issue of control, and I suggest that there are two sides of science, the beholding and molding, and there are two sides to parenting, accepting love and transforming love.

And by the way, there are two sides to the human body; a means of controlling the world, and a means of savoring the world. And most of the discussion of enhancement today has related to enhancements that increase control in a humanitarian culture that is pathologically driven towards this one-sided development.

And there may be no discriminal reforms to control it. It may require a revolution in consciousness, which of course the late '60s talked about. And they used drugs not for the sake of control, but for the sake of savoring.

And that is another reason there is a complication in the word enhancement, too. Enhancement is a means of control, but enhancement has a way of enlarging savoring. So it is an interesting issue.

And, of course, worried conservatives and worried liberals alike amongst parents worried about the use of drug enhancement in that culture, which was checking out of the world, rather than this intense slavery to the world.

I mean, I have a kid in Trinity School in Manhattan, a grandchild I should say, and another one in St. Albans. And I see it take over and shadow family life from 2, and 3, and 4 years of age on. It is really quite appalling what is going on.

But if one would talk about the two sides of science, which are really there. It is not just a question of collapsing science, because after all there is ancient science, which was concerned with beholding.

And it is modern science that has emphasized the other side of molding, and have we developed it one-sidedly, and it is an interesting issue.

But this is also reflected in the human body. On the one hand, we are identified with our bodies as a means of control — feet for walking, and hands for manipulating, tongue for talking, and so forth.

But the body on the other side is through the senses and is a way of being open to the world unbidden. And it is very interesting that disease attacks us at both points. It not only undercuts control — the guy with the heart attack suddenly used to control his world, and now he is controlled by others — but it also impoverishes the senses.

And then part of the controlling efforts of medicine can relate to both of these sides through disease, both disease as it assaults control, and disease as it impoverishes our ability to be open to, and savor the world as a gift.

The sleeping pill also clouds the mind. The tranquilizer may get rid of some agitation, but can leave the individual feeling like a fish out of water, gaffed and stunned at the bottom of a boat.

And so there are various ways in which the very effort to get at the problem imposes some ranges of the problem. That is a cluster of points, and I am not sure which you want to respond to.

CHAIRMAN KASS: Did you want to add something to this, Michael, or —

PROF. SANDEL: Well, no, I think that is magnificent. I agree with — I take that as an elaboration more than as a challenge. I think it is an eloquent elaboration of these themes, and I would say that it is really the one-sidedness, and this is really a reading of where we are in the moral culture.

It is the one-sidedness that leads to the — that makes it important to try to rearticulate the side that has been eclipsed or diminished by the impulse of mastery and control.

And which isn't to say that we should give it up. We need to try to find a way to hold the two as human powers, and capacities, and stances toward the world simultaneously.

So insofar as this is a polemic against the first pole, the one of mastery and control, it is for the sake of reversing what is a powerful one-sidedness in the culture, but I accept entirely and agree with everything that Bill has said.

CHAIRMAN KASS: Gil Meilaender.

PROF. MEILAENDER: This will in some ways follow up on Bill's points. In fact, I often learn from Bill, and it makes me wonder why he doesn't always vote the right way. I can't understand that.

But I actually have four points. I think they are all interrelated, and certainly the last three are. So I am going to do my own piggybacking here, Michael.

The first is a little different, but I would just like to hear you say a word or two about the word gifted in your paper. Is it a metaphor or not?

Iris Murdoch once said that your consciousness, your hyperagent if there ever was one, or will, had a glorious incarnation a century earlier in Milton, and his name was Lucifer.

And if we are to recapture the sense of giftedness, do we have to know ourselves as creatures, which means in relation to a creator, or is there — I mean, I don't know exactly what giftedness means there. And I would be interested in hearing you say something about that.

Now, point two is that in relation to the — in connection to the relation between parents and children, and I think, although I had to read your paper quickly, that you are really thinking mainly of the — and especially as you take the beholding and molding stuff, and so forth — you are thinking of the relation between the generations in some ways.

But we need help in making certain distinctions. For instance, parents are supposed to inculcate, and they are supposed to civilize, and they are even supposed to transform in some ways, though transforming love insofar as it gets placed over against accepting love in your paper, you know, is problematic.

And so we are supposed to accept, but accepting doesn't mean failing to inculcate. It doesn't mean failing to civilize. But somehow it means backing off from certain kinds of transformation. How do I know?

I mean, I certainly agree with the general point, but how far does that get me unless I have some criteria for distinguishing. The third point is if we think not about somebody molding someone else, but just about living our own lives, and not about self-other, but about one's own life, isn't there some sense in which a person is supposed to think of his life as a project that he undertakes?

And is that ruled out by your critique of hyperagency, or if not, sort of what is the right way to think about one's own life as a project. And then, fourth, and I think it certainly relates to what Bill said related to all of these points, is that it is true — or at least I am prepared to agree that part of being human is to understand our giftedness, and to appreciate the givenness of our life in certain ways.

But part of our nature is our freedom to reshape life as well. Every time I go to the dentist and have novocaine, I am very pleased that someone did not just rest content in what was given.

And so to be human is to be two-sided in this way; to be finite and limited by certain givens, but also to be free to reshape them. Okay. It's good that you want to nudge us back in a certain direction, and I actually agree with that.

I don't mind the tenor of that at all, but how do we know when the given exercise of our freedom is creative or is going to be destructive. I mean, that is really the question.

Even if we buy what you say, that is the question that we have to get at. How do we decide on any given occasion whether this is the exercise of freedom that transgresses and steps across a boundary, a given boundary that ought not be stepped across.

Or whether it is the exercise of freedom that makes us human, you know, and fulfills us. So I accept the kind of fundamental move, and these questions are all about kind of how far it will take us without the ability to make certain kinds of discernments and distinctions.

CHAIRMAN KASS: Michael, go ahead.

PROF. SANDEL: I will try to answer as many of the four briefly. First, on the idea of the gifted. Does that mean that we need to understand ourselves in relation to a creator as the giver of the gift?

I would say that this is a difficult question. My answer would be that one important source of this understanding and this orientation to one's self and to the world is or does come from various religious traditions.

So I think that broadly speaking to view life as a gift or to appreciate the giftedness of life is — and of nature, and of creatures within nature, one powerful source of that understanding is the source of religion, and various religious traditions.

And it is I would say a religious sensibility. I wouldn't say that though it is a religious sensibility, I wouldn't say that it requires necessarily religion or a belief in a giver of the gift.

I think that is an open question. But there may be multiple roots to this mode of understanding, and while many of the roots — and the most powerful and influential roots are religious, I wouldn't want to say — and I couldn't be confident in saying that that is the only available root.

As for parents and children, parents inculcating, civilizing, transforming, as well as accepting, how do we know, and how do we know when the exercise of our freedom is creative and when destructive?

I don't think that question admits to a general answer. I think that we have to confront ourselves with particular cases, particular instances, of the tension between molding and beholding, accepting and transforming, in the case of parents and children, and also in other domains.

And I don't think this admits of criteria that can be specified that would be very interesting or helpful in advance. As far as shaping one's own life, the idea of life as a project isn't as bound up with the idea of hyperagency, or is there a way of making sense of one's life as a project that still or that departs from the hyperagency.

I think that there is, and the way it would — the account one would give would be to view one's life as a project in the sense of a narrative, with a certain characteristic form, or point, or telos.

And what it means to live life as a project on this view would be to struggle, and to deliberate, and to wonder, and inquire as we went along the course of our life and faced important life decisions, and whether we are realizing the point or the purpose of the broader life story or narrative in which we find ourselves.

So I don't think the idea of life as a project commits us to willfulness, to the idea of willful choice or a hyperagency, if you incorporate in the idea of a project a certain story, with a point or a telos that we may only glimpse. But that we work out as the project unfolds.

CHAIRMAN KASS: A quick response.

PROF. MEILAENDER: Yes, just real quick on the last point. Does that require that rather than understanding one's self, does that require that one understand one's self as a character in this story, and not as its author?

PROF. SANDEL: Both. I don't think that those are mutually exclusive descriptions.

DR. KRAUTHAMMER: Can it be written by anonymous rather than be a signed author, and that I think is the distinction. Could I interject here, or would it be unwise, or —

CHAIRMAN KASS: I am torn. I mean, this is — the form of the discussion is in a way going to produce or make something very episodic as different people have different points to make, and they sort of go back and forth.

On the other hand, I have got a cue of about seven people who I think — well, let's see if we can collect some of these things and keep them on one topic.

DR. KRAUTHAMMER: I won't jump. I will wait.

CHAIRMAN KASS: Okay. What I have is Alfonso, and I have Robby, George, Mary, Rebecca, Dan Foster, Bill Hurlbut, myself, and Charles. But we can perhaps collect some of these. And, Alfonso, please. I try to be a policeman of topics.

DR. GÓMEZ-LOBO: I think I am going to be a collector. I don't think I am going to stray away from Gil's remarks, and some of the stuff that Frank said.

The first thing is that I was very grateful for this paper. I greatly enjoyed reading it, but it seemed to me that when I read it two nights ago that there was a certain incommensurability between the paper and the discussions as I expected them to take place, and as they did take place this morning.

And the reason is this, is that we are moving within the assumptions of contemporary technology. Now, I think — well, Heidegger, for instance, has tried to characterize contemporary technology, and just to point out a few things.

I think that the spirit of modern technology is that if you can do it, then do it. And if you can't do it, find a way to do it. And that is why it is this primacy of acting in our desires that gives us a very special view of nature. Now, I am of course aware that the concept of nature which underlies our discussions is the 17th century one as Leon mentioned.

But I think it is fair to say that human beings have tried to think about nature in different ways, and the mechanistic views of the 17th century is not the only way.

In fact, I would say that there is something that strikes me in everything that I have learned in this council, is that there has to be some concept of nature which is valid today, which is not reducible to that concept.

And by that I mean the following. I have seen that nature seems to be a very fine-tuned system of causes, which has room for imperfections. And that is why there is this urge to improve it.

But I think that we would be blind to say that there is no valuable, for instance, in certain natural occurrences, and certain natural events, and certain natural timings. Let me just give you an example of what I have in mind.

I was reading about these attempts to have — I think it was a 60 year old woman to have a baby, and I said to myself, well, there is something really odd here, and I thought about this lady fighting teenagers who is almost 80.

Now, all of us have had experience fighting teenagers I assume, and you need a lot of energy. So I said to myself, well, shouldn't one think that there is a certain wisdom, and that wisdom can be interpreted in evolutionary terms to say, well, there is a moment when child bearing stops and perhaps other human activities can of course continue to be practiced.

Now, my last comment is this. Even if we emphasize the technological view, the view that if it can be done, let's do it, and there are two things. One is something that Frank was calling our attention to, and it is that we are not sure what the good is in the operations of enhancement for the most part.

Nature is much too complicated a set of causes so that we can really think that we have a hold on it to say, oh, this enhancement, great. Let's go for it.

We have seen many times in these discussions that there are very serious questions concerning what would happen if this enhancement is attempted.

Well, there may be downsides which are really very worrisome. And the last point is this, is that even today technology relies on nature. Cloning, for instance, is a way of harnessing a natural power.

It is this business about cloning for — I'm sorry to go back to this stuff, but to stem cells, without admitting that we let nature form an embryo, and then the embryo develops by natural causality, and then comes the stem cells.

That is just forgetting the role that underlying given, if I may use your term, is there, even in an extreme of technological endeavor.

CHAIRMAN KASS: Thank you. Robby George.

PROF. GEORGE: Michael, I was struck as Charles was, and evidently Alfonso as well, by that point that you make at the conclusion of the paper about the ethics of — sorting out the ethics of enhancement, requiring us to reopen some questions that had really been closed off by the adoption of a certain mechanistic view of nature in the 17th century.

Now, when Charles challenged you as to whether that implied on your part a rejection of modern science, I thought that your answer was entirely correct and effective.

But I want to ask not so much about that as about whether a view that is closely associated with mechanism, the mechanistic view of nature in the field of ethics would have to be thrown over.

I do note in answering Charles that you didn't say that you want to hold on, and I am suspecting that it would have to be, no, you don't want to hold on to the mechanistic picture of nature.

That is really different from the answer. You were saying modern science doesn't depend on. We can affirm what is good in modern science without adopting an underlying view that perhaps many modern scientists hold that isn't essential to affirming modern science.

So I would distinguish the question of whether we ought to be mechanistics about nature from the question of modern science, and I take it that you do as well.

Now, it seems to me that if we accept the conception of giftedness that you have laid before us, and on the terms that you suggested, and without supposing that you are arguing for anything more than overcoming a one-sidedness that has been introduced by an obsession with control and so forth. So just on your own terms.

But if we accept if, and are prepared to act on it, whether individually, or as a community, and whether informally, or formally through our public institutions and through public policy, it seems to me that it follows from that — and I wonder if you agree — that we are prepared to suppose that there are times when it is necessary from an ethical viewpoint to forego the satisfaction of our wants or our desires for the sake of ends, for the sake of goods, that are understood as intelligentibity valuable and worth acting for the sake of, and worth practicing restraint for the sake of, and worth foregoing advantage for the sake of.

But which have their value quite independently of their capacity to satisfy wants and desires. And if that is right, then what has to be rejected is —

PROF. SANDEL: Well, I can give a short answer to that. Yes, sure.

PROF. GEORGE: Okay. But if that is right, then what has to be rejected it seems to me is the philosophy of non-cognitivism in ethics, which is in fact closely associated historically and philosophically with the mechanistic picture of nature.

And with that I think we would have to reject materialism, and determinism, and any reductionist view of judgments of value, and reductionist in the sense that it would reduce them to the material, or even to the merely emotional. And then the question would be —

PROF. SANDEL: Well, can I answer those? Yes, fine. I am all for that.

PROF. GEORGE: So, so far so good. Okay. Then just a quick question on Gil's point. In responding to Gil's question about the creator, and whether the gift implies the giver, you answered by saying that religion is a root to the understanding of giftedness, but perhaps not the only one, and that certainly seems right to me.

But what I wonder is whether it was responsive to Gil's question as he framed it. It seemed to me that the question wasn't about the root to grasping the point about giftedness, and then everything else follows that you and I agree on.

But rather it was does it follow from the reality of giftedness. If it is a true judgment, if it is an accurate judgment that there is a giftedness that we need to understand in order to act up rightly, does it follow from our grasp of that true proposition that there is a giver?

Is there an inference that is invited from the understanding of giftedness to the reality of a giver, and would it be less than fully reasonable to stop short of drawing that inference?

CHAIRMAN KASS: The President's council on Bioethics is now going to ask Michael Sandel about whether there is something like this psychological that basis is proof of the existence of god, and let the record show —

PROF. GEORGE: Well, it relates to something that Michael has written about I think very, very well, and ultimately it goes to the question of religion and public policy, and the place of religion in Michael's now famous critique of Rawls raises these questions.

DR. KRAUTHAMMER: Is it constitutional to offer an answer to that question?

PROF. GEORGE: In fact, you don't have to answer it. I do want to simply insert that I think what is really — that that is really what Gil's question boils down to.

CHAIRMAN KASS: It is all yours.

PROF. SANDEL: I would say that whether — if you accept all of what you have described, this rejection of mechanism, and therefore of non-cognitivism, and materialistic, and ethics, and all of that stuff, and if you are lead to be persuaded by the idea of the importance of this idea of gift or giftedness, does that commit you to a particular theology or religious view.

I don't know the answer to that question, but I think that is an important question that is suggested by this line of reflection, and the way that we would go about exploring the answer to that question would be to look at the different accounts that people might offer who accepted the views that you just summarized.

And to see which accounts of this idea of giftedness, or of certain limits on the project of mastery and control, made the best overall sense of these views.

And we are not in a position to do that here, but I don't take that to mean that it is not a good question, or a question that doesn't naturally arise out of this line of reflection.

So that is how that would be the next stage in this kind of investigation. We would have to have different people give various accounts, theological or otherwise, of how you might explain this orientation to nature, and to the world, and so on, and then we would have to see which ones among those made the most sense, and seemed the most plausible, all things considered.

PROF. GEORGE: I agree.

CHAIRMAN KASS: Mary Ann.

PROF. GLENDON: I am wondering how you would react to an interpretation of your paper. When I read it a couple of times, the sentence that really jumped out at me was the one on page 3, the beginning of the first full paragraph.

"The moral problem with enhancement lies less in the perfection it seeks than in the human disposition it expresses and promotes."

That seemed to me to be the heart of what you were saying, and as I thought about it, I thought, well, you know, teachers want to edit things. So, I was thinking if I were editing this, I would say that the moral problem with some forms of enhancement, because as Janet said, we all agree that there are some that are wonderful improvements.

And I would put an "s" on the end of disposition, and then it seemed to me that the heart of the problem is what dispositions exactly are we talking about. What is it that is worrying us about the dispositions that are expressed and promoted by some forms of enhancement.

And then I was thinking about some garden variety, non-dramatic forms of enhancement, the kinds of enhancement that in an affluent society we all engage in to some extent.

And it seemed to me that when this disposition — and here is a little elaboration of your paper that I wonder if you would agree with, but one disposition would be this kind of endless desires that I think we have to thank Dr. Diller for having called our attention to the idea that we may be establishing a State religion of consumerism.

This kind of desire after desire without reflecting on what kind of people are we being individually and as a society. And is that really the kind of people that we want to be.

We may have gotten into this without reflecting much on it, but then we are constituting ourselves in a certain way, and it might be time to think about it.

Another disposition, and maybe it is just another way of saying the same thing, we talk about enhancement as though there were infinite resources for all kinds of enhancement. But every choice that we make is a choice not to do something else.

So that you get into this situation where we spend a lot of money on diet aids, and Dan is right. Obesity is a horrible threat to human health, but we spend more money on diet aids than people in other countries spend on food, and they are starving.

So there is something wrong with that. Does that fit with your —

PROF. SANDEL: Yes to everything that you said. Both the editorial enhancements, and the elaborations of the human dispositions that are at stake here. Yes, I think in both respects that is not only in the spirit of what I was trying to say, but I think it is an improvement.

CHAIRMAN KASS: Rebecca.

PROF. DRESSER: I guess my comments are similar to a lot of those that have been made. This issue of line drawing and distinctions, and trying to decide when graceful acceptance and adjustment is appropriate, and when some sort of active intervention is appropriate.

So you said that repairing the given world is all right, but we should accord some weight to the given, and one of the problems is that we tend not to appreciate certain characteristics that might appear to be nuisance characteristics.

So I wondered if — and this is an inappropriate abbreviation of your very elegant analysis, but take — the argument is to take a broader view of the harms, costs, and I think somebody said downsize, of intervening in these ways. And that is really what our discussion should focus on, as well as perhaps the benefits of not intervening.

That it is just a richer understanding of what is at stake here. Is that really what you are arguing for, and I guess I would have two further questions.

One is did you or do you have any ideas about how this discussion, public discussion, should be orchestrated, and how do we go about encouraging parents, and doctors, and everybody to have this richer thinking about these interventions.

And then I wondered — you know, with genetically modified foods now, there is this precautionary principle; that if we don't have the wisdom to understand what the full consequences, negative consequences could be, we shouldn't go forward.

That is, in the absence of sufficient information, we should not go forward. Whereas, it seems to me that the tendency that we have today is that we think we should get some information, sort of basic safety information, but then if it looks okay, then let's try it. Our presumption is in the other direction.

PROF. SANDEL: Just briefly on how to orchestrate public discussion of these wider considerations. I don't have — I am not terribly optimistic that there is a good prospect of doing this.

If you look at the work of this council, and the tenure of the deliberations, it is rare even among groups who are taking up questions of bioethics and medical ethics, even before you get to the problem of how any such discussions are given later importance in the public arena.

So I think it is very difficult, and one of the reasons it is difficult was also touched on in the earlier session, and goes to Mary Ann's point about consumerism. So much of the public discourse has been inhospitable to this kind of discussion because we are swamped by ads, not to say campaign contributions from the pharmaceutical industry.

So if you look at the actual shape of how the public discourse is actually structured, I think there are powerful obstacles of that kind. So it is going to be very difficult, I think, which is why we are so far I think down the road in one direction of these two components of science, and of modes of understanding of parenting.

CHAIRMAN KASS: Dan Foster, please.

DR. FOSTER: I am not sure this is not going to be interpreted as sort of a dumb statement, but I do want to say before I make this point that I want to make that one of the things that concerned me today about the Ritalin and so forth is the whole thing looks fake to me.

It is an enhancement that is fake, because long term achievement doesn't occur. It is a fak if what he said is true. I mean, if you look at it two years out, there is something, and there is no difference.

And I think that is sort of a worrisome thing. The second thing that I would say is — and I am going to exempt medical care and medical research from enhancement in the usual sense, because I am absolutely committed to what medicine does.

We are involved in preventing premature death. We are involved in the relief of symptoms when a cure is not possible, and we are in the business of comforting during the walk through. That we are committed to, and that includes the research activity. But cosmetic surgery, and all of these other things seems to be trivial. And what I was really worried about follows from what Mary Ann said, is that — and it is not — well, what kind of message are we giving to our country, or to the society, or to the world, by the emphasis of let's say on education and four years of college.

I mean, the statement is made that the main thing that it will enhance is one's ability to earn money relative to somebody with a high school education. And money would be involved, I suppose, with pleasure, and power, and influence.

And so in one sense one could say that we are trying to reproduce in some sense the elite of the country, and you are successful if you can drive a BMW, or you spend all your life seeking for this. I am tremendously worried about the leaders and about greed, about greed.

And I am not talking just about Enron, and I am worried about this idea of go to school, and make more money, and get more consumerism, or whatever, because of greed.

There is going to be an issue of academic medicines coming out next week, and it has to do with the whole issue that we talked about, the patenting of genes.

We see the best that we have of people trying to get power and money out of knowledge that should be involved with the whole society. I just heard from David Korn from AAMC who we were talking with this week about somebody who is patenting the idea of a diagnostic work-up for Alzheimers.

That is to say, that if you measure APOE-e4, or E-4, you have to pay them, because they have put a thing together. I think we ought to look at this issue that is coming out there. There are 11 chapters on patenting and so forth.

I am worried about the message that comes out, because it is both trivial and may enhance the things that Mary Ann points out that are not the best of our society at all.

When I was a trustee of the Dallas Independent School District, and this was before the big city school districts were destroyed by the desegregation situations, we did something very interesting.

We had a very interesting Board of Trustees. We were the seventh largest district in the country, and we were not harmed by — we had plenty of tax base, and we didn't have militant teacher unions, and we had a perfectly workable ratio community.

We dealt a magnet school, for example, amongst other magnet schools, which was very interesting. It was a place that you had to go if you wanted to spend four years studying Russian. But it was also the only place that you could teach a kid to become an airplane mechanic.

Because our school board felt that we ought not to try to reproduce ourselves. There were four of us who were doctoral on there and so forth. It is a terrible mistake to try to reproduce yourselves.

I mean, sometimes some of my residents say that because you are a physician scientist, you will be disappointed if I want to practice internal medicine in a small town, and I said that's crazy. I just want you to be the best internist that you can be.

So I think this idea of a stereotyped achievement in school, or something else, gives a terrible view about values. I will tell you that I — well, our medical school takes care of the poor, and I also take care of a lot of really rich and powerful people.

You know, people like the President of GTE, and so forth, and I find that human values are much more often to be admirable in the poor, who have no resources, and who are sick and dying, than I see in the people who have all these attributes that might be called enhancements, with their facelifts, and their cars, and so forth.

I just don't want to give this sort of message about that, and it is one of the reasons that I resonated to what you put in here, and that Mary Ann talked about. We don't need to reproduce ourselves.

And as a matter of fact, if you wanted to enhance things better for the world, the best enhancer is money. And the best thing that you could do in the world is to get clean water.

It is not anything fancy, and I would like us to be a country that is at least equally concerned with whether our kids are going to get into a pre-school at two years of age, as I would be about the people who are dying throughout the world because they don't have any water.

And so I don't know whether — and as I said, it may sound dumb, but I just don't resonate to much of what we are talking about with enhancement here.

CHAIRMAN KASS: Let's see. Unless someone wants to speak to that, what I have next actually is Bill, and then Paul.

DR. HURLBUT: I actually just want to second that. I think we have a widening number of people, and I don't know how to say that correctly, but a growing trend in our society who view nature, or to revise our view of nature off of our traditional ideas, and see nature in a kind of evolutionary model.

And usually it is simplistic evolutionary theories, too, and one that emphasizes the arbitrary nature of the whole thing, like we are some kind of a chance-driven coincidence within a chaos, but that competition is very central to the whole matter.

And that morality doesn't necessarily flow forth within the — or to put it this way, that the material and the moral don't flow forth from a single source, but the moral is actually an agency in the service of social cohesion, and not something intrinsically rooted in a transcendent referent, or some deeper purpose woven into nature.

So that what you see is — and I see this in my students. I see a sense that really this is about competition on another level, and slowly but surely you get that drift back return to the guiltlessness of a predatory conscience basically.

You see a sense that if you can use something to transcend the genetic lottery, why not if you can use something to a personal advantage. You weren't made that way by any overall benevolent force, but you are just the product of a certain shuffling of genes or circumstances.

And then you face the odd kind of question that is implicit in the indeterminacy of human nature; that Simone du Buvoir once said that human beings are that species which by nature has no nature.

And so you add the post-modernist flavor to this notion of evolution, and the emphasis on power, and you get this kind of arbitrary drift of where you should go with all of this new power over nature.

I found something in Michael's write-up that struck me as worth asking you to elaborate further on, and that is that if you think about Buvoir's statement, the problem is that we do have an open indeterminacy, but it is built on a very complex and beautiful structure that allows this kind of freedom that we actually have.

And that is fragile, and that if we go fooling around with it too much that we will walk ourselves right out of the arena. That we will actually damage the very structure which gives us the possibilities of who we are.

The phrase that I liked in your statement was that you referred to disfiguring fundamental relationships. So I ask you to elaborate on that a little bit. Could it be that there is what you might call a series of concentric circles, at which there is human prerogative to intervene without disfiguring things, normal cautions.

But that there comes a level at which, or another level at which biomedical interventions are violating the very infrastructure of being, the very social cohesion that makes possible the kind of meaningful lives that we have? Do you see what I am getting at?

CHAIRMAN KASS: Michael, do you want to comment? Do you want to take it later, or —

PROF. SANDEL: Well, I don't have a good general answer. but I agree with the general point. But to specify it more fully, I think that we have to look, as we have been doing in earlier sessions, case by case, of the interventions to see whether there are instances of the impulse to mastery and control run wild, and disfiguring some important goods.

Or whether they are repairs of the given that are consistent with an appreciation of the goods, and so the reason that I hesitate to specify in general is that I think here we do have to take up the instances as they come along, whether it is Ritalin, or whether it is sex selection, or whether it is cloning, or whether it is longevity, or whatever the case may be, and have those discussions each time in the fullness and richness of the cases.

Because the goods at stake will differ, and these are discussions and deliberations that have to attend to the actual goods that are at stake, and how to articulate them, and see how they may be threatened by an intervention, and how they may survive and so on.

So this is really a framework for making sense of the particular discussions that we have about those goods when the particular enhancements or interventions arise.

CHAIRMAN KASS: I have Paul McHugh, Michael Gazzaniga, Charles, and myself, and then I think we will have exhausted ourselves. Who did I say first? Paul.

DR. McHUGH: First of all, I very much enjoyed this essay of yours, Michael. I enjoyed it for its content, and I also enjoyed it for its style. You are the person who I appreciate most who was able to write exactly the way he speaks.

And I can read this and say that this is Michael talking, and I enjoyed it for that reason. But there were several things that came up that I wanted to address, and not only your personal attention you drew to me, but also what Gil said about the issue of searching for criteria that would help us, and make us concerned about certain forms of enhancement.

Now, in certain ways of transforming human beings, the criteria that we have are very clear, and we can see certain agencies that do it extremely well, and bring on virtues that we wish to support.

For example, we have a very clear idea of what we want out of a United States Marine, and the United States Marine Corps is wonderful, it being able to produce these virtues in these young men, and women now, with great advantage by the way to the young men that it is a co-ed group.

I can expand on that and tell you more about that, and what it has done, for example, to reduce the alcoholism that the Marine Corps had previously ignored.

But the Marine Corps is very, very good at developing certain virtues, but not complete virtues. Some of the virtues of life are left out, and I thought that the criterion for which people bring children along are the criteria that they see as the kind of outcome that they really want in their children in character development, that every person ultimately in my opinion should become a self-conscious pilgrim.

And that parenting has the responsibility to bring that self-consciousness along, subduing some traits that might be excessive, and at the same time bringing on others, and appreciating them.

Now, I was extremely fortunate in that I was brought up by two very loving and very intelligent parents.

PROF. GLENDON: Patient parents.

DR. McHUGH: it was interesting, Mary Ann, some of them were — my mother was more patient in everything than my father, and yet both of them combined together to both affirm and to transform.

And there may be a question really when I was reading your article as to whether — and it comes back to what Bill was saying, whether there may well in most parental — and if we are lucky enough to have two parents, that it might be easier to have the feminine affirming and the paternal transforming.

And I don't want to get into that as to whether they have to have Y-chromosomes or two X-chromosomes, but the issue for me seems to be that many people require in fact these two kinds of people, or two kinds of elements, to work together in transforming character.

And one of the problems of the consumerist world here today is that the chance of having the kind of two parents that I had is much less often possible for other people.

And this is a tremendous loss in forming a self-conscious person who thinks about his or her traits, and tries to minimize his vulnerabilities and maximize his strengths, which parents help.

The problem that Ritalin exists for me is that so often in the process it short-circuits the character formation role of the parental pair. The parental pair in my case that could be patient enough for my restlessness, and at the same time committed enough to accept some aspects of the energy that was there to bring me directiveness.

And Ritalin has — Ritalin just takes that out of the formula to some extent. Now, if you have a disease, ADHD, there is no question that it is just want Dr. Diller said. If you have one of those children that we want to give Ritalin to in the middle there, we would all say help him, because we won't even be able to have a conversation.

But with the others who have unfocused energy, and that Ritalin controls, it may well interfere with the parental role of enhancing self-consciousness in the person about what will do better, and what will do less well.

And so I am very interested in what you are saying. I think we could expand it certainly in this idea of what should be better familial situations for people to ultimately bring themselves on, and what are the issues that enhancing may well disallow, and finally I would like to remind you that poor Huckleberry Finn didn't, like Paul McHugh, have two loving and intelligent parents. He had to learn it on his own.

DR. KRAUTHAMMER: He had Jim.

CHAIRMAN KASS: Indeed, and that is a serious point. Mike Gazzaniga.

DR. GAZZANIGA: Mike, let's see if we can cash this in here. You basically don't want yuppies to shuffle the genes. You want Mother Nature to. And let's say you really are against Ritalin, and let's just use it as a metaphor for enhancement.

So what you are sort of arguing for, and I think that a lot of people would come to those views, whether they come from a strict biologic position, a scientific position, or a religious position. There are all kinds of ways to get to those conclusionary points of view.

But the basic idea is that we want to get this issue before the public someone said. How do we get people thinking about this. So let's now imagine that you become President of Harvard.

And let's imagine that you are going to have a new doctrine, and the new doctrine is that no applicant to Harvard can be enhanced in any way. And we are going to check your Ritalin records, and we are going to check your pre-implantation genetic record.

We are going to see whether you took the Kaplan. Whatever it is, you can't do that, and we want breezy, natural intelligence at Harvard. Let's say that you put that as a — let's say the President of Harvard came out and said that is a pre-condition for applying to Harvard.

Now, that would get national attention, and they would all go to Dartmouth. But the specific question is imagine that before the President announced that he actually put that question before the faculty at Harvard, what would the argument and the discourse be amongst the faculty at Harvard to that proposition?

PROF. SANDEL: Does this also apply to the faculty?

DR. GAZZANIGA: No, that's too late.

PROF. SANDEL: I think it is an intriguing suggestion. I had not thought about it before. I don't know.

DR. GAZZANIGA: Well, we have your class here, and we expect them to answer this.

PROF. SANDEL: Maybe this is one of those questions where I would be wiser to defer to the students afterwards, and we will put that on their agenda.

CHAIRMAN KASS: Provided that they turn in their pills first, right? Charles Krauthammer, and then I will take a word, and then we will close it up.

DR. KRAUTHAMMER: Rebecca mentioned a little earlier about genetically engineered fruit, and it occurred to me that you would get an enormous public uproar both here and abroad when you mention enhanced tomatoes, but you don't get very much when you talk about enhanced children.

And perhaps that is why we are having this discussion, and I think it is reasonable and important for us to talk about enhancement, because it has been looked at up until now in a very narrow way.

I want to return to, which I think is the central and sort of original point in Michael's paper, and that is the one that Mary Ann focused on; that the moral problem lies less in the perfection that it seeks than in the disposition that it promotes in that hubristic disposition.

And that disposition is mastery, and I think, Michael, that overstates the case, because we appreciate and we want mastery when we are going after disease.

That same disposition to master nature is what has powered all of medicine, and has brought us to this fantastic position of relieving misery and suffering through the conquest of disease.

I think where we want to draw the line is to say that we want that mastery to go up until that point, but not until then, and invade the land of the normal.

And that I think is — we may from what I heard this afternoon, I think we may actually have something of a consensus for all of the differing points of view expressed. And that is that there is something troubling about that mastery when we are mastering what is otherwise the normal.

And I think the best example came this morning, and in the discussions this afternoon in the discussion of Ritalin. The notion that we have — I mean, Paul McHugh had pointed out that if we — there is a very small number of kids who need it, and we would all agree with that, and like obscenity, we would all recognize it and there would be no discussion. That is disease if you like.

And we would want to cure it, and there wouldn't be a question of the illegitimacy of the mastery in doing that. The problem is that we all know that under a charade of medicine that there is a huge number, millions of kids, being treated as if it were a disease, but what we are doing is altering the normal.

I love the image of the little Paul McHugh, running around and sticking pigtails in inkwells, and I am sure that he got the strap, but he didn't get Ritalin, and that is the way to do it.

And it is very disturbing that there are millions of kids who are getting now a drug which is — I mean, it may not have a long range effect that we can measure, but it sure is having a short range effect, and it is changing their character or personality and performance.

And that I think is disturbing, and that is where I think we really ought to draw the line, and for two reasons. One is the one that Michael talked about earlier, and I think that Elizabeth had raised it, is that the problem is that it is our own ignorance.

We are changing parts of nature, human nature, and that we really don't understand the things that we are actually doing. I think that as Dr. Diller had indicated, when you take a kid who may not be performing that well, you alter that performance, and there could be all kinds of other human characteristics in her or him that we are altering, taking the round peg and changing it so it fits.

In that sense, we are subtlely altering a person in a way that we may not even be aware of, and the hubris is thinking that we know exactly what we are doing, and that we are focusing on one measure of performance, and that is it.

And I think that in and of itself is problem number one. The second is a problem that Frank had talked about. There is something totalitarian about this alteration of the normal, and I also was struck by that slide, where it said oppositional disorder, because that is out of the Soviet lexicon.

That is what they did when they threw people into psychiatric prisons. Now, obviously this is not comparable, but the mind-set which allows you to treat oppositional disorders is truly disturbing, and when you unleash it on millions of kids backed by a huge industry, which is making money off of this, and as the drugs of enhancement are universal in their potential markets, as opposed to drugs for disease, there will be huge commercial pressures behind the enhancing drugs.

I think that it is truly disturbing. This is in Ritalin, and it is clearly a form of social control. It is a way in which a modern society, which has less toleration for what used to be called the masculine or male characteristics of obstreperous if you like, is suppressing it by the use of drugs. That's disturbing.

Now, it is not the most — it is not rampant totalitarianism, and it is not Soviet psychiatry, but it is a hint of what is to come, and the reason why we ought to be disturbed about enhancement in general.

I think Ritalin is the perfect example, and it illustrates the two problems with the kind of the mastery of the normal. One is that we have limited knowledge, and we think that we have more than we do; and second, we are exerting a form of social control over the normal, which in the end could be truly frightening.

CHAIRMAN KASS: Charles, I think you graciously stepped aside at the end of the last session, and I will pass since I will put some of my own remarks in writing for the next time.

Let me thank Michael especially, but the whole group for a very stimulating discussion. Would you like a last word, Michael? You are entitled if you would like.

Okay. If not, we are adjourned until tomorrow morning, and I remind council members that we will start at 8:30. Francis Collins will be here, and could I exhort you to be prompt.

And I would remind those that would like to stay and talk with the students will do so. We will take a 30 second break for the people who would like to leave, and then the rest of us can stay.

(Whereupon, at 5:30 p.m., the meeting was adjourned, to reconvene at 8:30 a.m., on Friday, December 13th, 2002.)


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