Redesigning People

In China a scientist has created two gene edited babies using CRISPR-cas9 in order to prevent HIV infection. These babies are usually referred to as designer babies. In this posting I will use the term redesign rather than design because people have already been designed by their genes and this design is shaped by nature and evolution. I will consider whether we should attempt to improve on that design by redesigning people and in what circumstances it would be permissible to do so. If we redesign a kettle we hope the redesigned kettle will be an improvement on the previous one. Intuitively it might be thought if we redesign a person the result will automatically be an improved person. However we must be wary of our intuitions and whilst it might be pointless to redesign a kettle which isn’t an improved kettle the same does not hold for persons. A kettle is designed for a single task persons aren’t. Someone might redesign a person to serve a specific purpose and such a redesigned person needn’t necessarily be an improved person when considered more broadly. Perhaps a person might be redesigned to be a better soldier such a redesigned person need only be a better soldier not a better person. Prior to considering specific wrongs which might arise if we redesign persons I want to consider the different ways in which redesigning might be wrong.

Redesigning persons might be wrong in three circumstances. Firstly we aren’t competent to redesign persons. Persons unlike kettles are highly complex and perhaps we just don’t have the expertise to carry out such redesign. If we accept the above then it would be unacceptable to redesign persons unfortunately in these circumstances we should be open to the rather unpalatable option that others such as aliens or even some advanced AI might be able to redesign us even if we can't do so. Secondly it might be suggested that whilst we don’t have the expertise to redesign persons now that we might acquire such expertise in the future. If we accept this option then whilst it would be unacceptable to redesign persons now it might become acceptable in the future and it would be sensible to debate the consequences of doing so now. Lastly it might be suggested that the act of redesign must always damage the redesigned person. Danaher explores two objections raised by Jurgen Habermas to redesigning persons in which the act of redesign damages the designee. Habermas argues redesigning a person would of necessity damage her because it would compromise her autonomy and status of equality. I will now consider the specific ways in which redesigning persons might be damaging. Firstly I will briefly consider how redesigning persons might cause damage to both persons and society by creating inequality. Secondly I will consider how redesigning a person might damage that person by compromising her autonomy.

Let us accept that Kant was right to insist that treating someone simply as a means and not an end in herself is morally wrong. It follows that if we accept that creating someone to serve our ends is equivalent to using someone to serve our ends then redesigning a person to serve the ends of another is wrong. It also follows that if someone redesigns another to serve her ends that there is a lack of equality between the designer and the designee. The choice of available ends to the designer and the designee are unequal. However why should we want to redesign a person to serve our needs? It seems probable that if our technology becomes advanced enough to redesign persons that it would also become advanced enough to design robots which aren’t, as yet, persons to serve the same needs. In this situation if we want an improved soldier, a robotic soldier would seem to be a better option than a redesigned person. Personhood would be an unnecessary extravagance and might even make the soldier less effective. The same seems true of most servants with one possible exception. Currently there is some interest in sex robots (1). However is sex with a robot genuine intercourse? I have argued that sex isn’t simply friction and as a result sex with a robot is really only an enhanced form of masturbation sex with robots . It is possible that in this situation someone might want to redesign a person to serve her sexual desires. It follows that it is conceivable that in some limited circumstances someone might want to redesign a person to serve her own ends. Such redesigning creates a person designed for the ends of another making her less equal. It follows redesigning someone to serve the ends of another is morally wrong because it creates inequalities between persons. Now let us consider whether redesigning someone in order to benefit that person might also create inequalities in society. Any society which contains both enhanced and unenhanced persons is likely to be an unequal one. It follows that we might have reason not redesign persons based on the potential damage it might do to society. How strong these reasons are will depend on the cost and availability of redesign. It is possible that redesigning persons won’t damage society. I now want to consider other reasons why redesigning persons might be wrong.

In what follows it will be accepted that to design a person in order to serve the needs of another is wrong. It will also be accepted that redesigning persons might be wrong if it creates unacceptable inequalities in society. It will also be assumed that if we redesign someone that we do so in order to benefit her. If we redesign someone in order to benefit her then this redesign is a form of enhancement. I now want examine whether redesigning someone in order to enhance her might damage her personally? Let us start our examination by considering a specific example. Some potential mothers suffer from mitochondrial disease and these mothers will normally have babies who will suffer from the same disease. Using IVF an egg taken from such a mother might be fertilised. The nucleus of this egg is then transferred to an egg with its nucleus removed which has been donated by another woman from which the nucleus has been removed creating a three parent baby. This is a clear case of redesign and it is hard to see in this case how being designed damages the designee. It also seems to answer one of the questions raised above as to whether we can effectively redesign someone, the answer is that we can at least in some cases. If we accept the above then redesigning persons is both possible and doesn’t always damage the persons involved. However are there some circumstances in which designing a person damages the designed person?

Let us recall we have excluded cases in which we redesign someone in order to serve the purposes of another and are only considering redesign in circumstances in which the redesign is intended to benefit the redesigned person. Such a redesign is a form of enhancement. Let us first consider the possibility that we can enhance only one capability and leave the rest of the designed persons capabilities unchanged. Perhaps someone might be redesigned to be stronger or have a better memory. Human beings are animals and it is hard to see from the viewpoint of an animal how such enhancement might damage the animal involved. Being stronger or remembering the hiding places of predators should give any animal an evolutionary advantage. Let us accept that enhancing a single instrumental capability whilst leaving the rest of some designed person’s capabilities unchanged doesn’t damage her physically. Much the same reasoning can be applied to enhancing several capabilities provided the remaining capabilities are unchanged. However human beings aren’t simply animals they are potential persons. Does the fact that some capacity or capacities have been chosen by another for enhancement damage her as a person? I now want to consider whether the redesigning of a person in order to enhance her damages her autonomy.

Let us return to my example in which we redesign someone to be stronger. How can being stronger damage someone’s autonomy even if this choice was made for her by another? It might be suggested that by making someone stronger we are enhancing her capacity for athletic prowess. It might then be further suggested that by enhancing her athletic prowess she becomes more likely to choose an athletic career and as a result we have limited her choices and compromised her autonomy. The same argument could be applied to redesigning someone in order to enhance other skills such as an improved memory. It might be suggested that such redesign is analogous to parents who encourage a child’s athletic prowess and that they too damage her ability to choose and as a result compromise her autonomy. In practice we accept parents who encourage their children’s athletic prowess.  After all what can be wrong with encouraging prowess in something which is beneficial? It might then be further argued that if we are prepared to accept encouraging parents who encourage athletic prowess that we should be prepared to accept parents who seek to increase this prowess by redesign. It seems to me that this argument is unsound because the analogy is not a close one as children can reject parental encouragement but they can’t reject redesign.

I have suggested that parents who encourage their children to excel in some activity don’t damage their children’s autonomy because their children can reject their parent’s choices whilst parents who redesign their children to excel in some activity might do so because their children can’t reject the enhancement. I would be unhappy to accept this suggestion for two reasons. Firstly I accept that whilst most parents who encourage their children to excel don’t damage their children’s autonomy some might. Parenting is about guidance and some parents try to direct rather than guide their children, such parents do some harm to their children’s autonomy, see parenting and excessive guidance . Secondly my objector is suggesting that the enhancement of certain capacities of someone makes it more likely that she will choose some option and that this increased probability damages her autonomy. I accept that enhancing someone’s capacity might make her more inclined to make certain choices but I want to argue this doesn’t damage her autonomy in all circumstances. Let us return to my example of parents who enhance their child so that she has greater strength. These parents have no specific life plan for their child in mind and only want their child to be stronger. Let us assume that the child decides to become a gymnast. Let us accept that her increased strength makes it both easier and more probable that she will choose this option. Does the fact that some option has been made both easier to choose and more probable to be chosen by someone due to her enhancement by others mean that her autonomy has been damaged? I would suggest that in these circumstances it doesn’t. In these circumstances our potential gymnast hasn’t been coerced and it is difficult to see how her greater strength could possibly alter her capabilities to make an autonomous choice. Making it easier for someone to choose some option isn’t the same as making her choose that option. It follows redesigning a child so she has greater strength doesn’t damage her autonomy. I would now suggest that the same argument could be applied to all her instrumental capacities including cognitive abilities such as an improved memory or quicker reasoning. The fact that someone else has chosen which capacities to enhance seems irrelevant in these circumstances as far as enhanced person’s autonomy is concerned. Accepting the above leads a the conclusion that redesigning someone so that she has certain enhanced instrumental cognitive or physical capacities which were chosen by others and these capacities make it more likely that she will choose a particular option doesn’t damage her autonomy in circumstance in which this redesign doesn’t affect her remaining capacities and should be permissible. If this wasn’t so then any educational establishment which offered a bursary to a student, which might make it more likely she would pursue an academic career could be said to be damaging her autonomy.

I have argued that any enhancement in circumstances which only enhances some of someone’s instrumental capacities whilst leaving her remaining capacities unchanged doesn’t damage her autonomy and that such a redesign should be permissible. However it is possible to enhance someone’s non-instrumental capacities. I now want to consider whether enhancing these capacities might damage someone’s autonomy. Ingmar Persson and Julian Savulescu have argued that there is a need for widespread moral enhancement in order to counter the existential dangers which our modern world poses (2). Perhaps in order to counter these dangers we should redesign persons so that they have an increased capacity for empathy.  Would such a redesign damage someone’s capacity for autonomy? It might be argued that if we increase someone’s capacity for empathy that this increased capacity would lead to an increased desire to help others which in turn might lead to a decrease in her ability to fully exercise her cognitive abilities. Her increased empathy overwhelms her ability to make autonomous decisions to some degree. If we accept the above then enhancing someone’s capacity for empathy might damage her capacity to make autonomous decisions. What is important in these circumstances is not simply that someone has chosen which capacity to enhance but that by choosing she has altered the relationship between the enhanced person’s capacities to choose or damaged one of them. If we accept the above then it might be concluded that if enhancing some of someone’s capacities alters her remaining capacities to choose or damages them then this enhancement damages her autonomy and this redesign should be impermissible.

Whether we should accept the above conclusion depends on the account of autonomy employed. There are many different accounts of autonomy and I will only consider two accounts here because most other accounts fall somewhere between these accounts for our purposes here even if the details differ. First an autonomous decision might be regarded as a good decision based on what the agent cares about together with some widely accepted norms. If we accept this account then if someone’s enhanced capacity for empathy compromises her ability to accept certain norms then her autonomy is damaged. If we accept this account of autonomy then we might limit any damage to someone’s autonomy by employing a dual enhancement that enhances both empathy and cognition which might lead to increased empathy across a wider domain, see widespread moral enhancement. Secondly an autonomous decision might be regarded as simply as one which accords with what an agent cares about. Clearly if we accept this account and redesign someone in order to increase her empathy we won’t damage her autonomy. I have argued elsewhere that we should adopt this second primitive account of autonomy because if we don’t autonomous decisions simply become good decisions and that we have no need for a separate account of autonomy. If we accept this second account of autonomy then we have no reason based on damaging someone’s autonomy not to enhance her capacity for empathy even if her enhanced empathy overwhelms some of her cognitive capabilities. However in these circumstances doing so would still damage her as a person. Persons have some capacity for reasoning and if we overwhelm this capacity we damage the person involved.

I have summarised the main conclusions which can be drawn from the above below.

·       It should be unacceptable to redesign a person to serve the needs of another.

·       Redesigning persons might create unwarranted inequalities in society. Whether these inequalities mean redesign should be impermissible will depend on the cost and availability of the redesign.

·       Redesigning persons in order to enhance one or more of their capacities whilst leaving the remaining capacities the same does not compromise their capacity for autonomy and should be permissible. Making some option easier to choose is not the same as damaging someone’s capacity to make autonomous decisions.

·       Redesigning persons in order to enhance one or more of their capacities when this enhancement means altering the relationship between her capacities involved in decision making might damage her as a person even if it doesn’t damage her capacity to make autonomous decisions and should be impermissible.

1. Danaher, Mcarthur, and Migotti, 2017 Robot Sex: Social and Ethical Implications, MIT Press
2. Ingmar Persson & Julian Savulescu, 2012, UNFIT FOR THE FUTURE, Oxford University Press.

A right to anaesthesia, a right to physician euthanasia?

In an editorial in Anaesthesia Julian Savulescu and Janet Radcliffe‐Richards suggest that many people who are against the deliberate killing of terminally ill patients who wish to die should have no objection to what is known as terminal sedation, bringing about unconsciousness for terminally ill patients until their natural death, see Anaesthesia . I agree with Savulescu and Radcliffe‐Richards that most people would accept that sedation for terminally ill patients is not wrong when death is imminent. In France in 2016 a law came into effect granting terminally ill patients the right to anaesthesia until death. Sinmyee et al go further and argue that a right to anaesthesia should be available to all patients who choose to end their life by starvation or dehydration, see Sinmyee . Would most people accept that sedation for terminally ill patients is not wrong when death is inevitable but not imminent? Perhaps a patient has a prognosis that he has only six months to live. Secondly would most people accept that sedation for terminally ill patients is not wrong when used to relieve suffering which they cause themselves by a refusal to eat or to drink? I’m not sure what most people would find acceptable in either of these scenarios. In this posting I will firstly briefly summarise the argument why it isn’t morally wrong to sedate terminally ill patients even if their current suffering is due caused by a refusal to eat or drink. I will then consider what implications accepting this argument has for accepting physician assisted suicide and voluntary euthanasia.

Let us accept that any competent person has right to refuse to take food and water. It might be objected that in some cases the person in question is unlikely to be competent due to eating disorders such as anorexia. However clearly this objection doesn’t carry much weight when considering terminally ill patients. Let us also accept that relieving pain is a legitimate end of medicine even when this lessens a patient’s life span. Let us still further accept that relieving pain remains a legitimate end of medicine even when this pain is due to self-harm. We treat drug users for their addiction. Lastly let us accept that if pain cannot be controlled by any other means that it can be controlled by deep sedation. It appears to follow that deeply sedating a patient suffering from a terminal illness, even if his immediate suffering is caused by his refusal to eat or drink, is a legitimate end of medicine. It follows that in these circumstances deep sedation would not be morally wrong.

Let us now consider how permanent deep sedation differs from death. For a dead person conscious life is over. Conscious life is also over anyone who will be deeply sedated until he dies. Of course for someone who is deeply sedated some important unconscious physiological processes such as breathing will continue. The same is not true of the dead. But do these unconscious physiological processes matter if someone will never resume consciousness or take part in life again? If they do matter who do they matter to? These unconscious physiological processes certainly don’t matter to the sedated person. If they doesn’t matter to the person involved why should they matter morally to others? It would appear to follow that there is no significant moral difference between being dead and being deeply sedated until death. If this is so is there any moral difference between a doctor deeply sedating someone until he dies and helping him die a good death if he requests help to do so? If dying and being deeply sedated until death are equivalent for moral concerns then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept physician assisted suicide PAS.

It might be objected that deep sedation involves no suffering whilst helping a patient to die might do so. However even if we accept this objection the above question might be reframed. Is there any moral difference between a doctor deeply sedating someone until he dies and deeply sedating someone prior to carry out his previously expressed wishes for voluntary euthanasia? If there isn’t any difference then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept voluntary euthanasia, which might require prior sedation, when requested by a terminally ill patient.

I now want to examine two major objections to the above conclusion. Firstly it might be objected that the above argument depends on the concept of a person and that when considering deep sedation and voluntary euthanasia we should consider human beings instead. My objector might argue that that matters is not whether a person continues to exist bur whether a human being continues to exist. What does it mean for a human being to continue existing? Is someone who will never regain consciousness but for whom unconscious physiological processes such as breathing continue still a human being? My objector might conclude the answer is obvious and is affirmative. However if we consider the concept of brain death commonly used in transplant medicine the answer is not obvious. Someone is brain dead if he has a permanent absence of cerebral and brainstem functions, however mechanical ventilators and other advanced critical care services can maintain unconscious physiological processes such as breathing for some time. Whether someone who is brain dead remains a human being is far from obvious for we can use his organs for transplant subject to consent. Why does brain death matter? It matters not simply because of a loss of cerebral and brainstem functions but because the implications of these losses. These losses lead to a permanent loss of consciousness. If the above is accepted then substituting human for persons doesn’t affect my original argument.

I now want to consider a second objection to my argument that if we are prepared to accept deep sedation of the terminally ill patients until death that we should also be prepared to voluntary euthanasia for such patients. It might be objected that I have slipped too easily from considering PAS to considering voluntary euthanasia and that the two aren’t equivalent. PAS is self-administered whilst voluntary euthanasia is carried out by a physician. I made this move because it has been suggested that PAS might involve suffering by the terminally ill patient. As a philosopher I am unable to say much about whether PAS might involve suffering. However I can say something about the possible scenarios. Firstly if PAS doesn’t necessarily involve suffering then my original conclusion stands. Next let us assume that PAS involves some limited suffering. In this scenario it might be questioned whether a terminally ill patient needs to be fully anaesthetised for PAS to take place? Perhaps a patient’s pain might be alleviated without affecting his cognitive abilities allowing him to carry out PAS. Once again my original conclusion stands. Lastly let us assume that PAS involves suffering that cannot be fully alleviated without full anaesthesia. In this scenario PAS isn’t possible with full pain relief. In this scenario the question changes and becomes, if we are prepared to accept deep sedation until death then why shouldn’t we be prepared to accept voluntary euthanasia?

In order to answer the above question I want to consider two further scenarios. In both scenarios I will assume the patient is fully competent. In the first I will assume that the patient is capable of initiating the start of his anaesthesia before his physician takes over and delivers a fatal dose. In this scenario why is the patient initiating his own anaesthesia? I would suggest he isn’t only initiating a form of pain relief. He is only initiating pain relief in order to die. In this scenario the patient’s actions resemble those of a patient undergoing PAS.  However the two are not identical. In PAS the physician only supplies the means and need not be present at the time of death whilst in the above scenario the physician must not only be present but also deliver the lethal dose. Let us accept that the physician’s presence or lack of it is not relevant morally. However we must ask ourselves whether the fact that the physician supplies the means of dying differs in a morally significant way from the physician applying the lethal dose. It might be suggested that this a case in which we could use the principle of double effect to explain the difference. I would be reluctant to accept this suggestion. When supplying the means to die the physician involved in PAS has the intention of allowing the patient to kill himself, it isn’t a foreseen consequence of something else. The physician’s intention is the same whether he is involved in PAS or voluntary euthanasia as described in the above scenario. It seems provided the patient involved is able to initiate his own anaesthesia that there is no morally significant difference between voluntary euthanasia in these circumstances and PAS. Let us now consider a second scenario in which the patient is unable to initiate his own anaesthesia. I would suggest that there are no morally significant differences between a physician carrying out voluntary euthanasia on a terminally ill patient in this scenario and a physician suppling him with the means to carry out PAS provided the degree of voluntariness is the same in both cases. However is the degree of voluntariness the same in both cases? In the case of PAS the patient’s intentions seem to be clear because he initiates the dying process. If a patient can initiate his own anaesthesia I have argued he is initiating his death and once again his intentions seem clear cut. However if a patient is unable to initiate his own anaesthesia his intentions aren’t quite so clear cut. Perhaps this situation can be remedied by a rigorous consent process and a clear last directive. None the less differences remain between this scenario and the one in which the patient initiates his own anaesthesia and for this reason I would be reluctant to conclude that the scenario in which the patient is unable to initiate his own anaesthesia is equivalent to PAS. The above suggests some consequences for the process of deep sedation. Let us accept that the deep sedation of terminally ill patients who are unable to initiate their own sedation and voluntary are equivalent. It follows if we aren’t prepared to accept voluntary euthanasia we shouldn’t be prepared to accept deep sedation if the patient is unable to initiate his own anaesthesia.

In this posting I have argued that the deep sedation of terminally ill patients should be morally acceptable. I further argued such sedation was a legitimate use of medical skills. I have also assumed that most people would find such sedation acceptable and less contentious than either PAS or voluntary euthanasia. If most people find PA and voluntary euthanasia unacceptable and deep sedation is a legitimate use of medical skills then such sedation should be an option for the terminally ill. I then examined the moral implications of accepting deep sedation. The main implications of this acceptance are summarised below.

1. If we are prepared to accept deep sedation for terminally ill patients until death then we should be prepared to accept PAS when this process does not involve suffering.
2. If we are prepared to accept deep sedation until death and PAS involves some suffering then we should accept PAS provided that this suffering can be controlled without anaesthesia.
3. If we are prepared to accept deep sedation until death and a patient is able to initiate his own anaesthesia then in these circumstances we should be prepared to accept voluntary euthanasia.
4. If we are not prepared to accept voluntary euthanasia then we should not be prepared to accept deep sedation until death when a patient is unable to initiate his own anaesthesia.