1. Luke Brennan
Medical research has relatively recently started to develop new methods for preempting many
forms of disease. These “enhancements” bring with them novel ethics concerns. In this paper I propose
to evaluate these concerns as they relate specifically to medically relevant enhancements--
enhancements that prevent disease rather than providing novel or enhanced traits.
These enhancements include, for example, somatic gene therapy or therapies that modify the
immune system. T-cell immunotherapy involves extracting the immune cells of cancer patients (often
those that are already sensitive to the cancer) and growing them ex-vivo to be later reinserted into the
patient (Perica, 2015). The use of dendrimers and other nanoparticles to assist in targeted immune
response could make humans resistant to diseases that today kill thousands (Willson, 2015). Gene
therapy has similar potential, as it could potentially provide a functional cure to HIV/AIDS (Tebas, 2014).
Though these procedures are certainly beneficial, it is not clear whether they should be standard
aspects of medical practice, especially if used preventively. This is the issue I will address in what
follows.
I will argue that most medically relevant enhancements are morally permissible procedures
because they themselves are not an evil to society, and because they do not significantly predispose
people to engage in ethically questionable practices in the future. I will then propose guidelines within
which these enhancements can be researched and used clinically. In order to establish the context for
my discussion, I will explain the conditions under which a medical intervention qualifies as an
“enhancement”; I will then identify the distinctive features of medically relevant enhancements. This
will put me in the position to argue that it is permissible, but not obligatory, for doctors to use these
enhancements to fight disease.
I. Defining Medically Relevant Enhancement
Before I go any further, I want to distinguish an enhancement from a medical treatment. One
important reason for such precise categorization is that doctors are professionally obligated to perform
medical treatments whereas they have no such obligation with respect to enhancements (Juengst,
2015). This distinction is also important because of the difference in ethical considerations for
enhancements as opposed to treatments, to be explored further on in this paper.
A tempting definition of enhancements, and one often used as a working definition, is that they
are “biomedical interventions that are used to improve human form or functioning beyond what is
necessary to restore or sustain health” (Parens, 1998). There are several problems with this definition of
enhancement. First, it fails to address potential non-biological enhancements, such as the use of
nanoparticles (Juengst, 2015). Second, this definition is unhelpful in the regulation of enhancements
since most enhancements use technologies that are, or could reasonably claim to be, involved in
medical treatments of some form. These such technologies must often be allowed to develop for their
role in treatments, but its use for enhancement purposes should be regulated or prevented. This is very
difficult to do both pragmatically and conceptually. Taking blood doping as an example, it is difficult to
control who has access to blood storage equipment because this equipment is necessary for blood
transfusions, which are necessary medical treatments. It is harder still to designate when a person
receiving blood is doing so as a treatment versus when it should be considered an enhancement
(Anderson, 1989). Third, it is often hard to determine what is necessary to restore or sustain health
versus what is sufficient. For example, when prescribing medication for a child with mild attention
deficit disorder, at what dosage does this go from a treatment to an enhancement? Another example is
whether a preventative therapy to make a patient permanently immune to all fungal infections would

2. count as a treatment or an enhancement. Would this change if the therapy were given in response to an
existing fungal infection?
To better clear the hazy distinction between enhancement and treatment, the normal function
account has been suggested, which describes medical treatments as treatments that address legitimate
healthcare needs, which in turn are characterized as an impedance on ‘normal species functioning’. This
is to be thought of more as a bottom threshold of function rather than a bell curve mean (Daniels 2000).
This conception allows for much more identifiable boundary between enhancements and treatments by
defining the common goal of medical treatments, and allows each treatment to be evaluated by how
well and directly it attains normal species functioning (Juengst, 2015).
There are, however, concerns raised about this account, including the fact that treatments for
things like acne may not be included as treatments, since these conditions do not impair normal species
function. Further, those with well-developed abilities which are compromised through injury or disease
would require enhancements to be restored to their previous state (Juengst, 2015). Further, a functional
level defined by a minimalist conception of normal species functioning may be very unattractive to the
vast majority of patients, but this unattractive level of functioning may become the extent of medical
treatment under the normal species functioning account. Considering all this, it may be tempting to fall
upon a disease based account to separate treatments from enhancements, where medical treatments
address health issues created by diagnosable disease and disability and enhancements do not. The
problem is that this account still allows for the ‘invention’ of new diseases to justify calling what are
really enhancements, treatments (Juengst, 2015). Further, for cases where a certain diagnosis cannot be
made but a certain treatment can control the symptoms none the less, this treatment would be
considered an enhancement, and the ethicality of its use may come into question.
Instead, let me propose a new account, an expected functioning account. This account considers
a medical treatment any procedure or therapy that returns a patient to the level of function that the
patient previously had for the organ system in question, provided that this previous level of function can
be determined. Instead of treating patients until they reach normal species function, patients would be
treated until they reach their own previous, expected level of function. This allows therapies that
restore patients’ talents to their previous levels, above and beyond normal species functioning, to still
count as ‘treatments’ instead of ‘enhancements.’ With this account, a runner with a broken leg can be
restored to his previous level of fitness in that leg through therapy, even if that same treatment would
be considered an enhancement for someone of a lower level of fitness before injury. Therapies for
patients with chronic conditions like type II diabetes that could bring patients to the level of functioning
they had before diabetes would also be treatments. A more difficult scenario comes when previous level
of function cannot be determined. This is the case in congenital conditions or other diseases that appear
at or before birth. In these cases, it would seem that there would be no choice but to fall back on the
normal species function account.
Further, there is no reason why the expected functioning account couldn’t allow healthcare to
include treatments to maintain one’s expected functioning instead of just correcting for its deviation,
preserving people’s capabilities instead of just restoring them. These uncontroversial clarifications make
it clear that on the expected function account, preventive medicine can qualify as standard medical
treatment (Juengst, 1999). This account allows many of the procedures described above in the paper
like preventative T cell immunotherapy or gene therapy to be classified as medical treatments
depending on how they are used. However, to avoid confusion and to adhere to standard medical
conception of enhancement versus treatment, these procedures will continue to be referred to as
enhancements rather than treatments.
Finally, it is important to draw at least a rough distinction between those enhancements which are
medically relevant, the focus of this paper, and those that are not. Medically relevant enhancements are
enhancements that primarily make people less apt to suffer from disease. These medically relevant

3. enhancements would not aim to have any significant impact on a person’s appearance or abilities,
though this may occur as an unintended effect in some cases. In other words, these enhancements
would not make patients more attractive, stronger, exceptionally intelligent, or give any such
‘experiential’ abilities. These enhancements would instead give people more resilient hearts, or immune
systems that can successfully repel HIV, abilities that could be considered ‘non-experiential’ beyond
their medical relevance. These enhancements could be thought to improve the body’s capacity to keep
homeostasis, rather than to give a patient new or improved traits.
These enhancements are set aside from the rest in this paper because enhancements that endow
people with new or improved abilities bring with them concerns about fairness and autonomy. Some
worry that those who can afford these enhancements would outcompete the unenhanced creating a
two-tiered society of the enhanced and the unenhanced, with a person’s tier determined by whether
she can afford enhancement. There are also questions about whether enhancements cheapen
achievements by using a ‘biomedical shortcut’ to avoid the practice and dedication normally necessary
for such an achievement (Malmqvist, 2011). Though these questions are important, they are not the
focus of this paper and can be found in literature elsewhere (Malmqvist, 2011; Juengst, 1999).
II. Should these enhancements be Obligatory?
Turning now to the use of such enhancements, we start with the most extreme argument in favor of
their use, proposed by new eugenists like Harris and Savulescu who believe that enhancements
(medically relevant and otherwise) are morally obligated as an application of the consequentialist notion
that we should do whatever possible to maximize wellbeing (Sparrow, 2011). The problem with this
claim is that there are several ways in which obligatory enhancements would not maximize wellbeing,
meaning that this claim does not apply in many circumstances. First, even though new eugenists claim
this obligation to enhance would be general, meaning that the obligation is not directed at any
identifiable person or group, and therefore no one is wronged if the obligation goes unfulfilled. Since it
no party could be harmed this general obligation could not justifiably be enforced, the government does
in fact enforce such behaviors for the public good as with emissions regulations and certain
vaccinations. Accordingly, there would seem to be no reason for the government not to take steps to, if
not mandate, at least encourage citizens to fulfill this obligation through incentives or heavy penalties.
Enforcement could also take the less direct form of social pressure from friends and family or even ad
campaigns like those to quit smoking that we have today. Although you can’t quantify the benefits of
whatever enhancements would be enforced, the autonomy and even identity of the citizenry would be a
very tall price to pay for the benefits the enhancements may bring. Second, enhancements that benefit
the individual do not always benefit greater society. If everyone did enhance themselves and their
children as much as possible, individuals would converge to one favorable phenotype for the given
society, often made favorable by the effects of social injustice on other phenotypes (Sparrow 2011). For
example, although being black may not offer any inherent disadvantage, in certain areas social prejudice
may make it quite disadvantageous to be black. In these areas, parents would be obligated to use
enhancement technologies to make their children Caucasian to avoid the disadvantages of social
prejudice. Those parents who do enhance in this way could be seen to have chosen to enhance because
they did not want their child to be black because of their own prejudice. In this way the parents could be
complicit in the promotion of the social prejudice that caused the parents to enhance in the first place
by appearing to ascribe to the prejudicial behavior themselves. At best, enhancing in response to social
prejudice in this way avoids the problem instead of addressing it directly, and at worst it promotes the
prejudice through the apparent complacency of parents.
III. Reservations about Enhancements: Accessibility, Argument from Nature, Slippery Slope

4. From the above section it seems clear that these enhancements should not be obligatory, however
it remains the case that these enhancements in themselves would be one way of improving the total
welfare of society. In fact, it would be hard to argue against the many potential benefits of most
enhancements on strictly their own merits. In most cases, these enhancements would allow people to
be ill less often and less intensely, translating into lower rates of death and morbidity, arguably the goal
of healthcare itself. Further, because of the preventive nature of many enhancements, chronic and
expensive conditions could be put off until much later in life or even eliminated altogether, making
death a swift and inexpensive process at the end of a longer life.
For these reasons the vast majority of the concerns about these enhancements come from
secondary concerns about their use, rather than their direct effects. As we consider a few of these
concerns below, namely concerns about accessibility, argument from nature, and the slippery slope, we
must be careful to consider two aspects of these enhancements:
(1) the benefits and risks of these technologies and how these will change over time
(2) which fundamental moral principles we should use to guide our evaluation
(Anderson, 1989).
The first concern is accessibility. The possibly costly nature of these procedures coupled with the
fact that most would be preventative in nature may make them inaccessible to many who cannot afford
the best forms of health insurance, if insurers choose to cover these enhancements at all. Obviously
fairness is central to this discussion because of both the health benefits conferred on those with access
to these enhancements, and the possibility that these enhancements could perpetuate unfairness by
lowering lifetime medical costs of those who can afford enhancements.
While this dilemma is concerning, the unfairness of this scenario is not inherent to
enhancements but instead another instance of unfairness from socioeconomic disparities. One could
have these exact concerns about any number of medical treatments and medications. If we take this
view even further, we could say it is unfair that Americans take any medications while there are those in
the world who have practically no access to modern healthcare. If fairness in access to a therapy
determines that therapy’s moral permissibility, virtually no medicine would satisfy this condition.
The reason why those treatments and these enhancements are morally acceptable for us is that
they do no harm to those without them and benefit those with them, so their use, even when used
unfairly, is a net benefit. While they may be unequally dispersed because of factors unrelated to the
nature of the enhancements themselves, like for example affluence, banning these enhancements for
this reason would help no one and harm those who would otherwise have access.
Of course, it would be ideal if everyone had access to these enhancements. It is certainly
conceivable that the government could include some preventative enhancements as part of
Medicaid/Medicare, or mandate them as part of health insurance plans. Such a policy may even save
the government healthcare costs by preempting costly and prolonged chronic conditions in its enrolled
citizens.
Another argument against the use of enhancements comes from the idea that we as a society
should not tamper with nature out of respect for our ‘natural state’ and for fear of possible ramifications
from disturbing a system that has been in ‘balance’ since life began.
The problem with this argument is that it is very difficult to find a rigorous distinction between
what is ‘natural’ and what is not. Penicillin was derived from a fungus, a natural source, but the forms in
which it is used today include the addition of synthetic elements to the base structure of Penicillin.
Would this be categorized as a natural or synthetic process? If it is the latter, should humanity give up
almost all clinically used forms of Penicillin and antibiotics like it? Vaccines are also hard to classify as
natural or unnatural. In essence, they are a way of getting the body to react to a stimulus that is very
similar to a certain pathogen, however vaccination injections include several synthetic adjuvants to

5. enhance the immune response. Should vaccines’ use also be limited because they interfere with nature?
Medicine itself is tampering with what is natural in one degree or another, and almost any treatment,
from beta blockers to putting on a cast, interferes with a natural process, but these all cannot be
regarded as regrettable acts. Indeed, it is clear that developing and using therapies that go beyond or
around natural processes for medicinal purposes brings far more benefits than harms.
One could also consider that in many ways, it is human nature to interfere with ‘natural
processes,’ medicine being one of many examples. As with technology, society, and economics, humans
categorically interfere with the natural order to improve their circumstances. It could be said that
humans by nature are predisposed to interfere with what is otherwise natural. This paradox makes it
impossible for humans to be clearly contrary to nature in the first place, whether they refrain from
interfering or not.
The last concern I will address is the slippery slope, the classic fear is that “[i]t would be difficult,
if not impossible, to determine where to draw a line once enhancement engineering had begun”
(Anderson, 1989). The distinction between medical treatments and enhancement determines where a
doctor’s obligation ends, but there is no significant moral distinction between even vastly different types
of enhancements. This means that individuals and policy makers cannot determine that any one type of
enhancement is morally permissible but that another enhancement is not morally permissible, because
there is no set criteria, or distinction, on which to base this determination. Without such a distinction,
could we justify a decision to give permission to do a treatment that confers resistance against HIV to
one patient but still deny another patient permission to do a procedure to double his IQ?
This logical slippery slope forces us to evaluate our acceptance of uncontroversial therapies that,
for example, confer resistance to a certain disease, based on the merits of the extreme cases like IQ
doubling, since there is no set moral distinction between the two. If it is the case that allowing any such
enhancements requires allowing these much more morally objectionable enhancements, then it would
be unwise to pursue any of the proposed enhancements for fear of also implicitly allowing significantly
more questionable enhancements.
The first response to quell this concern is the classic counterexample of vaccines. In a technical
sense, vaccinations are interventions where the immune system is artificially sensitized to a certain
pathogen. In other words, it is probably best categorized as a basic enhancement of the immune system.
Even though this enhancement was created over two hundred years ago, it still has not lead to any
other, more morally questionable practices. This must mean that either each therapy that could come
from vaccination was evaluated individually and those that were questionable were not pursued, or that
vaccinations fall into a category of practices which are deemed morally permissible, while questionable
practices that follow do not fall into this category and are deemed impermissible. This example of
historical evidence suggests that each enhancement is evaluated largely on its own merits, or that there
is in fact a moral line in the sand concerning enhancements which vaccines do not cross.
One possible choice for this moral line in the sand is a categorization of enhancements which
allow better maintenance of homeostasis, as opposed to those which go beyond. Vaccines are clearly on
the conservative side of this line, as are many other disease-preventing enhancements, genetic or
otherwise. This is because they stop the body from being damaged—the body itself is hardly different,
only its response to disease. The patient does not experience any difference in his traits or abilities,
except those that directly relate to the maintenance of his health, so he would get sick less often and
less severely. Enhancements that fall on the other side of this line are those that are meant primarily to
improve the traits that the patient experiences and in doing so go beyond the maintenance of
homeostasis, even if they may improve the maintenance of homeostasis better as a secondary effect.
These would include enhancements to boost performance physically or mentally. The key difference is
that these enhancements would involve experiential changes in how the person performs on tasks that
are not directly related to the maintenance of their health.

6. This distinction does leave the boundary case of therapies where the primary purpose is to
prolong life. While prolonged life could be seen as a prolonged maintenance of homeostasis, an
enhancement that allows a patient to live an extra fifty years could certainly be considered an
enhancement that goes beyond maintaining homeostasis. In this way it could be seen as an
enhancement by prolonged homeostasis, which falls on neither side of our aforementioned line in the
sand but stands right on the line, as it were. The degree to which the therapy extends life will almost
certainly play a role in which of these life prolonging therapies are considered medically relevant. The
medical community today almost uniformly encourages treatments, behaviors, and medicines that
prolong healthy lifespans. How long would a therapy have to prolong life in order to be qualified as an
enhancement? Also, for the many who think indefinitely prolonging one’s life is unethical, they must
consider how long a lifespan can be prolonged before this prolongation becomes unethical? Ten years,
thirty, one-hundred? An argument could even be made that it is never unethical to prolong life,
regardless of age. These questions are very difficult and certainly go beyond the scope of this paper.
These questions do, however, show that if we do categorize enhancements based on whether they
allow better maintenance of homeostasis, or go beyond to enhance experiential traits, the case of
prolonged lifespan must be given special consideration.
IV How to Determine What Regulations and Restrictions Should be Placed on Enhancement
Even with the distinction between different types of enhancements from the previous section, the
enterprise of selecting which enhancements to pursue and the manner in which to pursue them
requires careful oversight. It would seem that there would be three main concerns:
(1) Ethical practice in research
(2) Safety
(3) Justice in access to enhancement
These are truly complex issues in themselves, each practically representing its own branch of medical
ethics. Below I will highlight the special considerations that make enhancements different from medical
treatments in these three areas, and propose broad ways of addressing these issues.
(1) Ethical Practice in Research-
To determine how to ethically carry out enhancement research, we must consider which
enhancements hold enough promise to merit research and then the lengths we can ethically go to in the
course of this research. Further, we must consider how much risk a doctor can assume in researching an
enhancement that goes beyond his ethical obligation to provide medical treatment. For example, would
the standards for an enhancement drug to be allowed to go to human trials be more stringent than for a
therapeutic drug? Finally, there is also the question of whether research into an enhancement could
ever take precedence over research into a medical treatment. On top of all this, there is the pragmatic
consideration that failures with enhancements can be catastrophic, such as autoimmune attack on
cardiac muscle, and just a few such failures can effectively shut down an entire area of development
(June, 2014). When irresponsible or poorly planned research limits advances in an area of medicine that
could improve the welfare of patients, this irresponsibility becomes unethical, to say nothing of the
human cost of the failure itself.
A possible model for conducting enhancement research ethically may lie in how research is
conducted for preventative medicine. Just as with enhancements, preventative medicine could be
considered (though I cringe saying this) ‘less essential’ to health than medical treatments aimed at
already manifested diseases and conditions. None the less, research into preventative medicine is
funded well, as verified by the 2015 NIH spending estimates. Accordingly, there would seem to be little
reason to fund or investigate enhancements in a significantly different manner, since they prevent

7. suffering yet to come just like preventative medicine. Similarly, preventative medicine is given funds
that would otherwise go to other medical treatments, preempting them, so there is little reason to
believe that enhancements wouldn’t do the same. One could also argue for both preventative medicine
and preventative enhancements by noting that that investments in these procedures would prevent or
minimize the spending necessary to treat the manifestation of the disease. If we can prevent a majority
of cases of malaria with enhancement, then less money would have to be spent on malaria treatment.
Indeed, the similarities between enhancements and preventative medicine would make it reasonable to
use the policies already in place for preventative medicine research as a basic framework to establish
the policies for enhancement research. Such policies would also facilitate the evaluation of individual
enhancements against individual medical treatments, since the comparison would mirror that of
preventative medicine against (other) medical treatments.
We must also turn to enhancement practices that should not be pursued. Many believe gene
therapy involving the germline is one such example. Although germline gene therapy does show
promise in treating or curing diseases from HIV/AIDS, and some types of cancer, this is an area of
enhancement where research could be unethical (Carrol, 2014). Germline therapy raises concerns
because its effects are passed down to the patient’s children, grandchildren, and so on. Further, the
effects of these treatments are often unpredictable especially because the effects of modification done
to an embryo often cannot be detected until after birth (Lanphier et. al. 2015). These unpredictable and
long-lasting harms present in this therapy make its use with the field’s current body of knowledge
negligent, as many claim. Accordingly, many countries have ethics review processes to assess the risks of
experimentation on human embryos (Cohen, 2015).
When evaluating these morally questionable areas of enhancement research, one must consider
the likely benefits weighed against the possible risks. Therapies that show potential to bring great
benefit to a large number of patients can afford to involve potentially riskier research practices than
other therapies since the benefits seem to outweigh the risks. If the possible risks are vast or even
unknown, as in the case of some instances of germline gene therapies, it would be very hard to justify
research in these topics and prohibition would be nearly certain until the risks are better understood
and sufficiently limited (Anderson, 1989).
(2) Safety
Safety is also a big concern with the clinical use of enhancements. Safety risks with
enhancements are often different from those with medical treatments because, to oversimplify greatly,
the possible harms of medical treatments are compared against the harms of the disease they try to
address, whereas enhancements’ potential harms are compared against normal functioning.
Accordingly, clinicians would have to justify the inherent risk of a given enhancement therapy for a
person who would be healthy without the enhancement. For all these reasons, it seems clear that safety
standards for enhancements would be much stricter than those for medical treatments. At the same
time, the fact remains that if developed appropriately, many of these enhancements would do a great
deal of good for many people, quite possibly more good than many medical treatments. This leads to a
balancing act between more significant harms and potentially significant benefits.
Perhaps the role of informed consent will take on greater importance as patients decide
whether they want to assume the risks of enhancement in order to evade the risks of susceptibility to
the corresponding disease. Since enhancements go beyond the professional obligation of the doctor, it
makes sense to give the patient more control over her own choices.
(3) Justice in access to enhancement
Because doctors categorically are not obligated to provide patients with enhancements, the
question of ethicality in access becomes significant. Further, many of these enhancements could be

8. expensive or in limited supply, so decisions about which patients are given access to these
enhancements will be largely inherent in their use. Discrimination especially must be carefully avoided
in the allocation of limited enhancements.
The moral considerations for enhancements would be somewhat similar to the considerations
for medical care when the resources for that care are in limited supply. Norman Daniels explores this
topic in the scope of justice in healthcare. He posits that when no unified consensus can be reached
about “distributive principles for health care” (as is often the case) ethicists should retreat to procedural
justice as a way of determining what would be just in the given context. In this system of procedural
justice, four key criteria are used in making decisions about private and public health care “part of a
larger public deliberation about how to use limited resources to fairly protect the health of a population
with varied needs” (Daniels, 2002). These conditions include:
1. disclosure of rationale for limit-setting conditions
2. decisions should reflect a rational conception of per dollar value of healthcare according to
relevant guiding principles
3. decisions can be challenged and revised
4. there is a method of enforcing the three previous conditions
(Daniels and Sabin, 1997). It would seem that this same system of procedural justice could be used to
make just determinations about the dispersal of enhancements.
Medically relevant enhancements stand to bring great benefits to patients. They also bring the
potential for danger and injustice that must be mitigated with care. In this paper we have defined
enhancement using the expected functioning account, and made the distinction of medically relevant
using the concept of homeostasis. These definitions were necessary to clearly categorize therapies
properly for the later discussion of ethics, determining whether the doctor is professionally obligated to
do the therapy, and whether the therapy is compared against the symptoms of the disease or against
normal functioning. We then addressed the question of whether we are obligated to pursue these
enhancements, deciding that while we may not be obligated, enhancements’ benefits on balance make
them worth pursuing. After addressing three concerns about the pursuit of enhancement categorically,
we conceived of conceptual frameworks and distinctions to address concerns of ethicality in research,
safety, and access to guide the research and clinical use of these enhancements. Although great care
must be taken with these enhancements to ensure their benefits are maximized responsibly and
ethically, it would seem that they have the potential to bring medicine into an enlightened age.
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