Moral Distress and Autonomy

In Ian McEwan’s book 'The Children’s Act' we have a clear example of moral distress. A judge has to make a decision which is in a child’s best interests when these conflict with his parent’s autonomous wishes. This posting will consider moral distress. What do we mean by moral distress? Moral distress was defined by Jameton as a phenomenon in which someone knows the right action to take, but is constrained from taking it. (1) Moral distress is usually considered in a medical setting but can occur in other areas. For instance a soldier might feel moral distress when carrying out an order which she believes to be morally wrong. It is important to clearly differentiate between distress in general and moral distress. For instance a nurse might be distressed because she feels empathy for a patient’s suffering. However her distress isn’t moral distress. It is also important to be clear about difference between distress caused by moral dilemmas and moral distress. For instance someone might feel distressed because she must either lie to a friend or cause her friend to suffer. She doesn’t know the right thing to do and is experiencing a moral dilemma but not moral distress as defined above. A nurse helping to resuscitate a terminally ill patient suffering great pain might become distressed because she feels she is carrying out an action which she believes is wrong, is suffering moral distress. Moral dilemmas are self-imposed. Moral distress is imposed on the sufferer by others. Both moral dilemmas and moral distress can cause moral injury which can be harmful but in this posting I will only be concerned with moral distress.

What sort of others can cause moral distress? I would suggest moral distress can be caused by two sorts of others. Firstly it can be caused by some authority. This might happen when there is a difference between what someone believes is the right thing to do and what some authority with power over her wants her to do. For example a soldier might suffer moral distress when ordered by her superiors to shell a village which she believes contains a large number of civilians. In a healthcare setting if systems are set up to provide good ethical guidance for healthcare workers this form of moral distress might be reduced. Such guidance might be particularly important during health care emergencies such as the covid-19 outbreak. Secondly moral distress can be caused by respecting someone’s autonomy. For instance a nurse who continues to give a competent patient treatment, which she believes is futile and causes suffering, because the patient requests that her treatment continues.

Most work on moral distress focusses on distress caused by authority. In this posting I want to consider moral distress caused by respecting someone’s autonomy. I will argue that sometimes such distress is sometimes inevitable and difficult to reduce. Someone suffering from moral distress believes she is being asked to do something she believes is wrong. This wrong can take two forms. Firstly respecting someone’s autonomy means that she is asked to do something which conflicts with her beliefs. Secondly respecting someone’s autonomy forces someone to do something wrong by preventing her from acting beneficently. It might be suggested that one way of averting moral distress is for the person suffering the distress to opt out from carrying out the action which is causing the distress. However opting out isn’t easy for someone who believes in respecting autonomy. I would suggest that if you care about someone then you must care about what they care about to some degree even when what they care about conflicts with your beliefs. Caring about someone makes opting out of helping an autonomous person achieve her goals difficult. Caring about differs from caring for. I can care for someone whilst ignoring her wishes but this form of caring is caring in much the same way as someone cares for a child or even a dog. Caring about someone means that the cared about person’s autonomous decisions must carry some weight to the carer and cannot be easily dismissed by the carer. I would further suggest that someone cannot feel genuine empathy for someone if she doesn’t care about what the person she feels empathy for cares about.

Let us assume that respecting autonomy matters and that autonomy is a useful. First let us consider someone who is in moral distress because respecting someone’s autonomous decision means she feels she is prevented from acting beneficently. For instance the nurse in the example I have used above. I would suggest that if the nurse accepts that respecting her patient’s autonomy matters that her moral distress is inevitable. It might be objected that my suggestion depends on a particular account of autonomy and that if we adopted a different account her distress could be avoided. I am using a primitive or Millian account of autonomy. My objector might then suggest that if we adopted a substantive account of autonomy which requires that an autonomous decision must be in a patient’s best interests that the conflict between acting beneficently and respecting autonomy would disappear and with it the moral distress. In response to my objector I will now argue that if we accept a substantive account of autonomy that this account becomes redundant. Let us assume that an autonomous decision isn’t simply some decision made with only reference to what the maker cares about but must also concur with some substantive norms. An autonomous decision must be a good decision. However if we accept that an autonomous decision can’t be a bad decision then the whole idea of an autonomous decision isn’t really much use and we can simply replace all autonomous decisions by good decisions. Let us consider a nurse caring for a terminally ill patient who has one treatment option withdrawn, which the patient desires, because it is regarded as a futile option. If the nurse in question believes in a substantive account of autonomy then this option withdrawal against the patient’s wishes means she will feel no moral distress due to a failure to respect patient autonomy; the patient’s wishes weren’t good wishes because the treatment option was futile and hence weren’t autonomous wishes. If we accept a substantive account of autonomy then the idea of an autonomous decision becomes redundant and can be replaced by a good decision. If we accept that autonomy matters we must be prepared to accept that autonomous decisions can be bad decisions. We must be prepared to accept a primitive account of autonomy. Accepting that autonomous decisions can be bad decisions means that respecting autonomy and acting beneficently will sometimes clash causing inevitable moral distress. It might be argued that opting out of acting might combat this moral distress. I would argue that this option isn’t available in a caring setting. In a caring profession caring about what someone believes to be wrong way is better than not caring at all. It follows that respecting autonomy in a caring profession sometimes makes moral distress inevitable.

My objector might accept a primitive account of autonomy but still suggest that moral distress is not inevitable. She might suggest that autonomy is connected to of my “real self” as opposed to my empirical or actual self. She might proceed to suggest that if we did so my ‘real self’ wouldn’t make bad decisions and that respecting autonomy wouldn’t lead to moral distress. This might lead to the position where someone might think it right to ignore an agent’s intuitively autonomous decision because she believes it does not reflect his real self. I would reject my objector’s suggestion for two reasons. Firstly the world is populated by real people rather than idealised people. Secondly if we accept autonomy is only connected to idealised people who don’t make bad decisions then once again the concept of autonomy becomes redundant and can be replaced by good decision making,

Let us now consider cases where respecting someone’s autonomous decision causes moral distress because it conflicts with the distressed person’s beliefs. For instance a nurse’s religious beliefs might mean she believes we must do all we can to maintain life. Let us assume that she is nursing a terminally patient who isn’t in pain and is expected to continue enjoying a reasonable standard of life for some time. Let us also assume that this patient has made a last directive stating that if she goes into cardiac arrest that she isn’t to be resuscitated. The patient goes into cardiac arrest and the nurse suffers from moral distress because she can’t resuscitate her. Our nurse’s distress is caused by respecting her patient’s autonomy expressed in the last directive. I would suggest that in such scenarios respecting autonomy makes moral distress inevitable. Once again an objector might reject my suggestion. She might attempt to do so not by suggesting that we replace a primitive concept of autonomy by a substantive one but by limiting the domain of autonomous decision making. The domain of autonomous decisions is limited to those decisions which don’t clash with certain basic or religious beliefs. In the example used above the nurse might not suffer moral distress due to respecting autonomy because she believes the patient’s decision isn’t really an autonomous decision because it doesn’t belong in the domain of autonomous decisions. She may of course be forced to respect it by authority. Most hospitals have a policy to respect patients’ last directives. However the basic cause of her moral distress remains respecting patient autonomy. There are two arguments against accepting my objector’s suggestion. Firstly it might be argued that restricting the domain of autonomous decision making removes the importance of autonomy and makes it peripheral to our lives. Someone might end up in a situation in which she could autonomously decide to have an ice cream but couldn’t autonomously decide to have sex if she wasn’t married. Autonomy is about self-government and self-government must of necessity include those decisions which are central to our lives. If the nurse above suffers no moral distress due to respecting autonomy by adopting a limited domain of autonomy then her lack of distress is due to her adopting a deficient idea about the domain of autonomy. Secondly I would argue that any such limitation autonomy is really a surreptitious attempt to reintroduce a substantive concept of autonomy. The domain of autonomous decisions is limited because a larger domain would permit some people to make bad decisions. It is now possible to employ the argument used above against substantive accounts of autonomy. If autonomous decisions cannot be bad decisions then the concept becomes redundant. It follows that respecting someone’s autonomous decision inevitably causes moral distress when the decision conflicts with the respecter’s beliefs.

I have argued that the moral distress caused by respecting autonomy is sometimes inevitable and must simply be accepted by us as the price we pay for viewing other people as the sort of creatures who can decide how to live their lives. We may of course try to get someone to change her mind but if we can’t then respecting her as a particular person and not some idealised person means accepting her decisions and sometimes that means accepting moral distress.

1. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall

Honour in a Cosmopolitan Society

In the western world the idea of honour seems to be becoming less important. Politicians make promises and feel no shame when they break them, others offer apologies without feeling any sense of shame. In a new book Tamler Sommers argues that honour matters. Let us accept that honour matters. Sommers argues that in our cosmopolitan culture we have replaced honour by dignity and that this replacement damages society. In this posting I will argue that some of the goods honour delivers can be outweighed by other goods delivered by a dignity based culture. I will then argue that honour can matter in a dignity culture albeit in a modified form.

Why does honour matter? Sommers lists three main disadvantages of living in a culture without honour. Firstly he argues that such a culture makes us fearful. Secondly he argues that the rampant individuality of contemporary western leaves us without a sense of solidarity. Lastly that such a society diminishes the power of shame. Honour matters to Sommer because it gives us courage to combat fear, it helps to form our identity and it gives us a stronger disposition to feel shame. Honour matters because these goods are valuable.

Let us accept that courage is valuable, Martha Nussbaum like Sommers argues that we are damaged by living in a fear driven culture (2). However it might be argued that in a cosmopolitan society courage has diminished because the need for courage has diminished. For herders or hunter gatherers courage helped them to survive in a harsh environment. For a citizen in ancient Greece or Rome courage helped flourish in brutal times. However most of us no longer need courage to survive even if we might need it to flourish. Perhaps as the need for courage diminishes so does its value. It might be concluded that in a cosmopolitan society because we have less need for courage that this is on balance a good thing. It might be objected that some inner city dwellers live in a harsh and brutal environment which means that the need for courage remains. Perhaps this is one of the reasons why gangs persist in these areas. I would suggest what this objection shows is not that there is still an undiminished need for courage in a cosmopolitan society but rather that the domain of such a society is limited. A truly cosmopolitan society must address the needs of all of its citizens. I would further suggest that in an efficient cosmopolitan society which addresses the needs of all its citizens that there is less need for courage and that as a result the value of courage diminishes.

However even if it is accepted that there is less need for courage in a cosmopolitan society this does not imply we have no need for courage. It is sometimes remarked lose it or use it. If there is less need for courage in such a society does this damage our capacity to display courage when needed? I am prepared to accept it does but would suggest that any harm done by a lack of courage in a dignity based society is more than offset by living in a more peaceful society which protects its citizens. Perhaps the harm done by living in a fearful society might be better addressed by hope supported by faith as suggested by Nussbaum (3). In this context faith might regarded as the realistic optimism of Tiberius. Nonetheless I still believe courage should be fostered. Our educational systems seem to be becoming solely concerned with preparing people for work rather than life perhaps with more emphasis on sport and perhaps even the teaching of philosophy might foster courage.

Is Sommers right when he suggests that the rampant individuality of contemporary western leaves us without a sense of solidarity? It might be argued that a dignity culture means that all are valued. Perhaps all being valued gives all of us a basic sense of solidarity. However this is a very basic sense of solidarity and I accept Sommers is right and that rampant individualism can damage solidarity. A sense of solidarity can have various roots. It might be rooted in a profession, a religion, class, a nation or even a tribe. However even if a sense of solidarity has benefits it might have shallow roots. Let us accept our identity is linked to solidarity. We identify with those who are similar to us. If our sense of identity is rooted in some class, nation or tribe then our identity is passively determined and our sense of solidarity is easily acquired. Such a sense of dignity might increase solidarity with our own in group but lessen our sense of solidarity with others and lead to a decrease in toleration. Perhaps these harms outweigh the solidarity an honour culture fosters. Can a dignity based culture deliver a sense of solidarity other than a very basic form? In a dignity based cosmopolitan society we determine our identity to some degree. We might do so explicitly by choosing profession, such as joining the police force, or choosing a religion, perhaps by becoming a Buddhist. We might also do so implicitly by the actions we choose. I would suggest that if we choose our identity, even if our choice is implicit rather explicit, that we are more authentic than if are identity is acquired passively by being, born in some particular place or class. I would argue that even if solidarity is of value that the loss of solidarity in a cosmopolitan society might be more than offset by the value of authenticity. However at this point courage re-enters our discussions for someone wants to be true to himself must have the courage of his convictions. Does someone in this situation really need raw courage or would fortitude be more useful? I would also argue that a cosmopolitan society might increase a stronger sense solidarity in some cases. I have suggested above if we passively acquire our sense of solidarity that this is easily acquired. I have suggested that identity and solidarity are linked. If our sense of identity is based on partly on the choices we make we might feel a stronger sense of solidarity with those who have made a similar choice rather than those who are simply members of our class, nation or tribe.

Sommers argues that we are less likely to experience shame in a dignity culture than in an honour culture. I agree with Sommers that the ability to feel some form of shame is valuable but what form of shame? What do we mean by shame? I have previously argued that there are two types of shame. Firstly David Velleman defines shame as “anxiety about social disqualification” (4). This seems to be the sort of same fostered by an honour based culture. Secondly shame might be defined as someone’s anxiety about harming the things he cares about or loves and is linked to character. If we accept Velleman’s account of shame then a cosmopolitan society does indeed damage our ability to feel shame. A cosmopolitan dignity based culture seeks to include rather than exclude. But is Velleman’s type of shame really valuable? Consider a high caste Brahmin in India who has come into contact with something unclean and feels no shame. Has he done anything wrong and would social disqualification ever be valuable in this scenario? Shame is valuable but I would suggest that the type of shame which is valuable is linked to character. But shame linked to character is linked to authenticity which is perhaps best fostered in a cosmopolitan society than an honour culture. If we accept the above then shame matters and the shame that matters is connected to character. Such shame is not the shame fostered by an honour basis.

Let us accept that Sommers is right and that a loss of a sense of honour damages society. He argues honour is connected to being a member of some organisation such as a profession, a religion, class, a nation or even a tribe. If honour is only connected to some social group then in a dignity based society honour becomes irrelevant and fades away. I have argued if honour depends on the above bases that the goods delivered by a cosmopolitan outweigh the damage done by losing our sense of honour. Sommers argues that honour is damaged by an excessive focus on dignity. Perhaps it’s not our excessive focus on dignity but our excessive focus on rights, rather what it means to be a good person, which damages our sense of honour. I would suggest being a virtuous person is connected to being a good person. I would further suggest that being virtuous is not incompatible with living in a dignity or rights based society. I would still further suggest honour can be based on acting virtuously. Indeed it might be argued that virtue based ethics is impossible without some idea of honour. Moreover acting virtuously sometimes requires courage, gives us a sense of identity and if we fail a sense of shame. Such thoughts might have pleased Jane Austin. If we accept the above that being honourable means acting virtuously then honour is possible in in a dignity based or rights based society. Perhaps to promote honour we don’t need to encourage a greater sense of solidarity in our cosmopolitan society as suggested by Sommers but rather by encouraging people to be good persons by acting virtuously.

1. Tamler Sommers, 2018, Why Honor Matters, Basic Books, chapter 2
2. Martha Nussbaum, 2018. The Monarchy of Fear, Oxford University Press
3. Nussbaum , chapter 7
4. David Velleman, 2009, How We Get Along, Cambridge University Press, page 95

Grief

 

A robot cannot grieve. Stoics want to limit our dispositions to grieve. In this posting I want to examine grief. This examination was prompted by John Danaher’s examination of coping with grief , my examination not a direct response to that of Danaher. The purpose of my examination is threefold. First is grief a useful emotion? Secondly how grief is related to love and does this point to the emotions being connected. Lastly I will consider how much grief is appropriate. I will conclude that to be fully human someone must be prepared to accept vulnerability and with vulnerability comes grief. Prior to my examination we must define grief. Roughly speaking grief is distress caused by someone’s death. Grief has a focus, the death of a loved one and as such is a genuine emotion as opposed to depression and sadness which have no real focus and are perhaps better described as moods.

In the past if someone ventured into the forest at night her fear might have kept her safe provided of course it wasn’t over excessive. Other emotions such as guilt, shame and perhaps even anger can be useful emotions. Can grief also be a useful emotion? I would argue it can’t. For someone venturing into the forest at night her fear focusses her attention on danger and this focus benefits her by helping keep her safe. In a similar way someone’s anger is focussed on some perceived injustice and this focus might help her right this perceived injustice. The focus of someone’s grief is the death of another and it is hard to see how this focus can be useful her. It might be objected that grief is not just an emotion but a social construct and that an appropriate display of grief is useful in demonstrating that someone is part of that social order. Someone who celebrated the death of her spouse would become a social outcast. However displaying grief is not the same as experiencing grief and in this posting I am only concerned with the latter. Consider Robinson Crusoe and Man Friday on their desert island. Let us accept Crusoe loves Friday, not in an erotic way, but cares about him. Let us assume Friday dies and Crusoe grieves for him, does his grief serve any useful purpose? Clearly Crusoe’s grief serves no useful purpose by displaying that he is part of the social order. I would also argue that Crusoe’s grief because of Friday’s death doesn’t benefit Crusoe in any way. Indeed his grief might harm him by lessening his focus on important needs such as obtaining food and maintaining his shelter. It would appear that in answer to my first question is that grief is not a useful emotion.

Guilt and shame are negative emotions but might help focus our attention on doing something useful. Grief doesn’t focus our attention on anything useful. In the light of the above it might be concluded that because grief is a negative emotion serving no useful purpose that we should seek to eliminate it. I am reluctant to accept such a conclusion. I have argued that grief has a specific focus and that considered in isolation grief isn’t a useful emotion. Let us accept if we grieve about someone that we must have cared about or loved the person we grieve about. Wantons and psychopaths can’t grieve because they don’t care. Grief is not the same as sorrow. I may be sorry I’ve broken the cup by dropping it but I don’t grieve about it because even if it was my favourite cup I didn’t care enough about it, I didn’t love it. Grief and love are connected and grief cannot be considered in isolation. The reason why we grieve is love. Some animals appear to grieve, see Jessica Pierce . Grieving animals seem to support the above conclusion. For why should animals grieve for it would seem grief serves no evolutionary purpose? Any mother’s love serves an evolutionary purpose if grief and love are connected and this connection might help explain why animals grieve. If grief and love are connected then other emotions might be connected. Can someone said to be brave if he recklessly defends something he doesn’t care about? Some virtue ethicists believe the virtues are connected by practical wisdom (1). Perhaps the emotions are connected by loving as defined by caring about. I will not pursue this suggestion further here.

Let us consider my last question, how much grief appropriate. Perhaps because grief serves no useful purpose we should seek to eliminate or reduce our grief as much as possible. Let us accept that loving is part of leading a flourishing life. I have argued above that grief are love are connected. The question we must now try to answer is this, would seeking to eliminate or limit our grief damage our capacity to love? Psychopaths don’t feel grief and don’t care about others and it might suggested that this means if we can’t grieve that we can’t love. However this is only a suggestion and it might be pointed out psychopaths don’t seem to feel most emotions. In order to answer the above question I want to consider one aspect of love. Can anyone love something without making himself vulnerable to the fate of what he loves? A stoic might argue someone can I would suggest he can’t. If someone is indifferent when bad things happen to something he loves then he cannot be said to love that thing. What does it mean to be vulnerable to something’s fate? It means if the something is harmed the vulnerable person is also harmed. This harm isn’t physical, it involves a negative mental affect. I would further suggest that if someone suffers negative mental affect focussed on the loss of his beloved that he is grieving. If we accept the above definition of grief then it is perfectly possible to grieve for something which isn’t a person. It seems to me to make sense to say that someone can grieve over the death of much loved dog. It follows from the above that grief is inextricably linked to our capacity to love and that any attempt to limit our grief will also mean limiting our capacity to love. In response to the above it might be objected that when the object of our love dies our love should cease and that love gives us no reason not to try to limit our grief. In response to the above I would firstly suggest that love cannot just be simply switched off and on. Perhaps in special circumstance, such as a child on learning his father has murdered his mother, love might be abruptly terminated but not in normal ones. Secondly I would suggest that when we become vulnerable due to love that we don’t simply become vulnerable to the beloved, whatever that might mean, but specifically to harm befalling the beloved or the loss of beloved. When someone dies this loss is ongoing. It would appear that the answer to my second question is that accepting some grief is the price we pay for loving

Let us accept we should be prepared to accept some grief. However how grief is appropriate? Let us also accept that even if we can’t abruptly stop loving love can fade. If love fades over time then we have no reason based on our former love to continue grieving as our vulnerability decreases. As our love fades so should our grief. Accepting the above then might explain why even if the reasons for our grief don’t expire over time our grief diminishes nor because the reasons change but because we change. Human have a continuing need to love and be loved and what we love helps define us. In the light of the above it might be argued even if someone’s beloved has deceased the lover can satisfy his need for love by loving her memory. Derek Parfit seems to support this objection with his example of a Russian nobleman asking his wife to be true to his former self if he changes. (1) In response to this objection I would suggest that loving the memory of someone is an incomplete form of love. Loving isn’t purely passive the lover seeks ways to benefit his beloved over time, love is a bit like gardening. It follows if someone’s grief is based on the memory of a deceased beloved that his love is incomplete in some way because he cannot actively try to benefit his beloved. Let us accept that a more complete form of love is preferable to an incomplete form. It follows that if obsessive grief damages our ability to love our friends who remain in a more complete way that we should seeks ways to diminish and over time eliminate this grief.

 

1. Julia Annas, Intelligent Virtue, Oxford University Press, 2011, page 94
2. Derek Parfit, Reasons and Persons, Oxford: Oxford University Press, 1984, page 327

Germline Gene Editing and Savulescu's Procreative Beneficence Principle

The possibility of using engineered enzymes to alter DNA means germline editing seems to be becoming a practical possibility with CRISPR. Such a possibility raises important ethical concerns. Some of these ethical concerns are concerned with safety but in this posting I will assume these safety concerns can be successfully adressed. In this posting I want to consider whether these possibilities mean parents should adopt Savulescu’s procreative beneficence principle using such editing. I will then consider two objections to doing so. Firstly it might be objected that the adoption the principle would lead to inequality and create some sort of genonobility. Secondly that the adoption of the principle might mean that in the future parents who use germline editing to enhance their future children damage these children’s autonomy.

Savelescu’s procreative beneficence principle states that prospective parents using IVF should choose among embryos so that the embryo selected if it became a child would be expected to have the best life, or at least as good a life as any other resulting child, based on the relevant available information. This principle can be broadened. It seems that in the reasonably near future that a combination of IVF and germline editing means that prospective parents would be able to use these techniques to enhance any possible child so she is expected to have the best possible life based on the available information. It appears follow from the procreative principle that provided germline editing is completely safe parents should select children who are expected the best life possible. Savelescu’s argument is a consequentialist one and if we accept the premise, that it is possible to predict the sort of life a child will lead, then provided we are consequentialists we should accept Savelescu’s principle. Should we accept the above premise? I would question whether we can really predict now that some possible future child will have the best life possible in thirty or forty years time. I would suggest that whilst we might possess some relevant information we don’t possess enough of it to make accurate predictions. If we accept the above then it follows prospective parents would have no reason why they should adopt Savelescu’s procreative beneficence principle, even if they could afford to do so and safety concerns had been allayed. However even if prospective parents cannot be certain that they are acting beneficently if they adopted the principle when conceiving future children does this mean that they shouldn’t do so in the hope that these children have the best possible lives? I would suggest it doesn’t. If we can’t choose to do x for beneficent reasons then this doesn’t mean we can’t choose to do x provided by doing so we don’t do any harm. If we can’t use the principle of beneficence then we can use the principle of non-maleficence. In the light of the above it might be suggested that provided germline editing is safe then it should be permissible for prospective parents to use it to apply principle when conceiving a future child in the hope that they are acting beneficently provided in doing so they aren’t doing any harm.

I now want to consider two objections to the above suggestion. It might be objected that the use of the procreative beneficence principle to conceive future children might harm society and might also harm these future children by damaging their autonomy. I will consider each of these objections in turn.

For many parents the costs involved with using the procreative beneficent principle are likely to be prohibitive and this means the use of the principle would not be open to all. Let us assume that some parents use the principle and that as a result their children have, on average, greater cognitive skills or physical abilities. It might then be argued that permitting the use of the principle would create a less equal society and that because a less equal society is damaging we should prohibit the use of such gene editing. It might even be suggested that over time the use of the principle would lead to a two tier society with a genenobility. However such a strict prohibition would harm some people affected by genetic diseases which might be treated by germline editing. Let us accept that germline editing should be permitted to combat specific diseases. However even if we permit germline editing for therapeutic purposes it doesn’t mean we shouldn’t prohibit it if it is being used to apply the procreative principle.

Let us now specifically consider germline editing with the express aim of creating children who are expected to have the best possible lives. However even if germline editing does create a less equal society this fact doesn’t alone mean it should be prohibited. Kant famously argued ought implies can. It might be that whilst a prohibition on such germline editing is desirable that achieving it is impractical. For instance whilst doctors in the US are presently prohibited from using gene editing tools on patients those in China aren’t, see Wall Street Journal . However even if a worldwide prohibition is possible it doesn’t mean it is desirable. For instance private healthcare and education also lead to inequalities. If we are prepared to accept the inequalities caused by private health care and education it might be argued by analogy that we should also be prepared to accept inequalities caused by some parents using germline editing to apply the procreative principle. The soundness of this argument depends on closeness of the analogy. It might be that such editing would lead to far greater inequalities than those caused by private healthcare or education. The question whether we should prohibit germline editing becomes no longer solely dependent on the creation of inequality but also depends on the degree of inequality created. Let us assume for the sake of argument that germline editing produces greater inequality than private health care or education. It might then be argued that this greater inequality means that it should be prohibited provided that this is possible. Such an argument also seems to be unsound. Even in these circumstances it still might be acceptable to accept germline editing, provided that the inequalities it created were only for a limited period. Inequality matters, the degree of inequality matters and the length of time this inequality persists for also matters. Clearly any permanent inequality such as that which might lead to a genenobility is unacceptable and in these circumstances we should prohibit germline editing provided of course we can do so on a worldwide basis. However it is possible that germline editing might be acceptable if it only produced greater inequalities for a limited period. It seems probable that many people would be prepared to undergo some inequality if this inequality was for a short period and they benefitted from it in in the long term. Would the introduction of germline editing only produce inequalities for a limited period? I would suggest we have two reasons to suggest it would. Firstly experience teaches us that the cost of any new technology falls over time. Secondly I would argue governments have reason to subsidise germline editing. If germline editing is likely to cause inequalities then this is likely to be due it creating children with better cognitive and physical abilities. Citizens with better cognitive and physical abilities are likely to be less costly to society and as a result the state has reason to encourage such citizens. Presently it does this by means of health campaigns and education. Perhaps in the future it might do so by subsidising germline editing. In light of the above before permitting germline editing in order to apply the procreative principle we should consider how long any inequality produced by such editing is likely to persist. If after careful consideration we come to believe that such inequality will be a temporary matter then have no reason based on inequality to prohibit germline editing in order to apply the procreative principle.

Let us now consider the second objection to parents using germline editing to apply Savulescu’s procreative beneficence principle. It might be objected that any parents who do so damage their future children’s autonomy. This objection can be split into two parts. Firstly it might be argued that any children conceived using the principle might not have consented in retrospect thereby damaging their autonomy. Secondly it might be argued that any children born using the principle have already had their future partly determined and this again damages their autonomy. I will consider each of these parts of the objection in turn.

Let us first consider the autonomy of someone whose germline has been altered by the decision of her parents. It might be argued that because such a person couldn’t have consented to these changes that her autonomy has been damaged. I believe that such an argument is unsound. Let us accept that consent and autonomy are sometimes connected. Let us also accept that if a doctor operates on a competent patient without her consent, when it is possible to obtain her consent, that her autonomy is damaged. However a failure to obtain consent isn’t always linked to damaging autonomy. Consider someone who is unconscious after a serious road accident and needs surgery. If a doctor operates on her without her actual consent in what he perceives to be his best interests then he is acting in accordance with her presumed consent. In these circumstances it would be wrong to say that he has damaged her autonomy. Indeed, it might be argued that he preserved her autonomy. She might have died or been severely handicapped without his intervention. Let us now consider someone whose germline has been altered. It might be argued by analogy that someone who could not consent to her germline being edited hasn’t had her autonomy damaged because her parents have acted in accordance with her presumed consent. However the analogy between the two cases is not a close one. In the case of the accident victim an actual person already exists making it easier to foresee her wishes. In the case of germline editing we would be trying to foresee the wishes of a hypothetical person at least a decade and a half later.

In the light of the above it might appear that it should be impermissible for parents to adopt the procreative principle because any child conceived using this principle because they have no reason to presume that she would have consented. I would argue this appearance is also unsound. The above appearance depends on connecting our inability to obtain consent or presume consent with doing nothing. Let us assume that sometime in the future germline editing becomes reasonably cheap to use and will not result in any future children having cognitive or other health problems. In these circumstances potential parents have to decide whether or not to use the procreative principle when conceiving a future child. Not adopting such editing is a decision. I have suggested that it would be difficult for parents to ascertain what would be in a child’s best interests decades later. In these circumstances it is hard for potential parents to make a decision based on beneficence. However provided safety concerns can be fully allayed there seems to be no reason why parents shouldn’t use germline editing to apply the procreative principle. In response to the above it might be objected that children whose germlines have been edited would most probably not consented rather than consented. I find this objection based on hypothetical probabilities unconvincing. The present discussion is concerned with germline editing for beneficial reasons. In this scenario is it really more probable that the recipient would think in hindsight that she would have refused consent? If we reject the above suggestion above, then once again we have no reason to reject germline editing used to apply the procreative principle due to our failure to secure consent.

Let us now return to the second part of the objection to prospective parents use germline editing to apply the procreative principle based on damaging autonomy. It might be objected that the use of the procreative beneficence principle to conceive future children might harm these future children by damaging their autonomy. Autonomy roughly speaking is the ability to govern oneself by deciding what is best for you. How might this ability to decide be damaged? It might be damaged in two ways. Firstly the mechanism by which we decide might be damaged. Secondly our ability to decide might be damaged by limiting the choices we can make. If parents use germline editing to apply the procreative principle the any resulting children are likely to have improved cognitive or physical abilities in order for them to live the best possible life. If someone has improved cognitive or physical abilities then these abilities are more likely to enhance her mechanism to decide than damage it. It follows that if we only improve these abilities that we can discard the first reason not to permit germline editing. If parents use germline editing to apply the procreative principle might any resulting children have more limited options when making decisions than if no editing had been applied? Options might be limited in two ways. First there might just be less options and secondly someone might be less able to exercise the options available. It seems improbable that altering someone’s germline will alter the number of potential options. It also seems improbable that germline editing will alter someone’s ability to exercise some of these potential options. If someone parents used germline editing to apply the procreative before she was born then her cognitive and physical abilities should at least be equal to those which would have pertained had not such editing taken place. It follows that germline editing to apply the procreative principle won’t damage her ability to exercise potential options.

I have concluded that whilst we don’t have solid reasons to apply Savulescu’s procreative principle using germline editing that we do not have reasons based on inequality or damaging autonomy to make it impermissible. However a note of caution is needed at this point. The above conclusion depends on the assumption that germline editing is completely safe. The truth of this assumption might be difficult to ascertain in practice as some of the effects of such editing might not become evident in humans for decades. For this reason if we are ever to use germline editing extremely rigorous safety standards would need to be applied.

Why I'm not a Stoic

I admire fortitude, detachment and many other stoic virtues but believe full blown stoicism is damaging. Let us accept that for someone living in an extremely deprived environment with limited options that these virtues can help him to survive. An account of how stoicism can help people survive in such circumstance is given by James Stockdale who was shot down in the Vietnam War and detained in Hanoi, see Stockdale . Someone who suffers from a life limiting disease might also find himself in an extremely deprived environment and once again with few options. In these deprived circumstances adopting a stoical perspective seems to be a sensible option.

Fortunately, most of us don’t live in such circumstances. The question I wish to address is this, in more normal circumstances should we lead a stoic life? Some stoics believe that the only thing that always makes us happy in life is leading a life of virtue.

“The only thing that always contributes to happiness, as it is necessary and sufficient for the condition, is virtue. Conversely the only thing that necessitates misery and is “bad” or “evil” is the corruption of reason, namely vice.” Internet Encyclopedia of Philosophy

Perhaps virtue is the only thing that always makes us happy but I will argue there are some things which even if they don’t always make us happy are nonetheless essential for a happy life. Certain things such as fame and material goods might make us happy temporarily.  However, we can’t always attain these goods and once attained these goods might not always make us happy. Let us accept that the excessive pursuit of these goods can damage our happiness in three ways. Firstly, we might be disappointed if we fail to obtain these goods, secondly even if we do obtain them they might fail to meet our expectations once again leading to disappointment, lastly the pursuit of these goods might divert us from the one thing that always makes us happy namely virtue. Let us consider the harm done by disappointment first. A stoic would argue that in order to avoid such disappointment that whilst we might prefer such goods we should remain indifferent to them. I would suggest that with regard to disappointment stoicism is a philosophy of pessimism by rejecting hope. A stoic shouldn’t hope because hope would make him vulnerable to disappointment. Let us assume that the excessive pursuit of fame or material goods hinders us from pursuing the only thing that always makes us happy, virtue. A stoic would argue we should always pursue virtue and as a result we not pursue those things which damage this pursuit. Let us agree with our stoic that we should first of all pursue virtue. Let us also agree that the excessive pursuit of fame or material goods damages this pursuit. However, it is by no means clear that using balanced Aristotelian moderation in pursuit of these goods will damage our pursuit of virtue. Accepting the above means that in normal circumstances that we have no clear reasons to accept or reject Stoicism.

 

At this point someone might object I am misunderstanding the stoic idea of happiness. I am confusing stoic ideas with Epicurean ones. An Epicurean is concerned with hedonistic happiness whilst to a Stoic happiness is concerned to living our lives in accordance with essential nature as rational creatures. For the sake of argument let us accept my objector’s point. Let us also accept that stoics believe that if someone leads his life in accordance with his essential nature that he will flourish.

 

I now want to examine what is meant by flourishing. Flourishing is a slippery concept. For instance, could it really be said that a creature, which leaves behind plenty of descendants, flourishes? Using a Darwinian idea of flourishing it certainly does. Moreover, it might be argued evolution means leaving behind plenty of descendants is selected for and hence is part of the nature of all living things. However, a Darwinian idea of flourishing, at best, plays only a small part in most people’s idea of flourishing. A stoic idea of flourishing seems to depend on the essential nature of a creature which defines it. For instance it is part of the nature of bees to collect nectar to make honey and a bee flourishes if it makes lots of honey. It is part of bee eater’s nature to eat bees and it flourishes if it eats lots of bees. The stoics emphasise it is an essential part of human nature to act rationally. According to the stoics a human being who acts completely rationally should flourish. Let us now consider a rational person who is virtuous, ratiomal, rich and healthy but lacks any positive affection for any of these things. According to a stoic this person flourishes. However intuitively we would not say such a person was flourishing. Indeed, we might feel that there is something defective about him. He lacks something that is necessary for flourishing. Perhaps one of the things he lacks is happiness and we should leading a stoic life can lead to happiness. I won’t pursue this point any further here. However, I would suggest one of the things a stoic lacks is a caring attitude to things in general.

 

Let us accept that stoics belief it is our nature to be rational. I have suggested above that such a belief is too simplistic and that other things are an essentIAL part of our nature. I will now present two arguments in an attempt to show that caring about things is An essential part of our nature. First, let us accept that someone’s ideals are defined by what he cares about. Now according to Harry Frankfurt,

“a person without ideals, there are no volitional laws he has bound himself to respect and to which he unconditionally submits. He has no inviolable boundaries. Thus he is amorphous with no fixed shape or identity.” (1)

Someone without fixed shape or identity is still of course a human being but she isn’t really a person. Almost all human beings develop into persons. Being a person is part of our nature. It follows caring about something must also be part of our nature. Secondly let us assume that caring about things is not part of our nature. If this is so being rational becomes pointless. It is impossible to apply rationality unless we care about something; it is impossible for rationality to get any purchase if we don’t care about anything. All our rational decisions are equally good and we have no basis to choose between competing options. It follows if caring about something is not an essential part of our nature then it isn’t possible to act rationally without caring about some things. Rationality is one of these things but isn’t sufficient. In the rest of this posting I will assume that caring about something is an essential part of our nature.

 

Even if we accept that caring about things is an essential part of our nature this give us reason why we should reject stoic ideals. A stoic might point out that he cares about virtue and rationality. The question is not whether a stoic cares about things but whether he cares about enough things. I will argue that he doesn’t. In order to make my argument I must make it clear what I mean by ‘care about’. David Hume famously argued reason is the slave of the passions. However, I want to argue what we care about doesn’t simply means that we feel passionate or emotional about something. Indeed, I would agree with the stoic idea that reason can control our emotions, at least to some degree. Reason can sort out our conflicting emotions and add stability to our sense of ever changing emotions. However, let us accept that reason alone cannot cause us to act. Our actions are based on what we will which is based on what we care about. According to Frankfurt “the formation of a person’s will is most fundamentally a matter of his coming to care about certain things, and of his coming to care about some of them more than others” (2). Also according to Frankfurt cares about’ something then he, “identifies himself with what he cares about in the sense that he makes himself vulnerable to losses and susceptible to benefits depending upon whether what he cares about is diminished or enhanced”. (3) A similar but slightly different approach concerning identity is taken by Bennett Helm who argues we are identified by what we love (4). If we accept the above definition of ‘caring about’ it can be regarded as a form of loving. In the rest of this posting I will use the word love to mean ‘caring about’ as defined above. It is important to note the use of the word love in this way is using a broader definition of love than simple romantic or erotic love. Let us accept that loving is an essential part of our nature, let us now also accept that to love something or someone means to identify oneself with that thing or persin and that to identify with something makes one vulnerable.

 

I want to argue that if someone leads a stoic and limits his love to virtue and rationality that he stunts himself and denies himself of the opportunity to lead a good life. First however I must introduce the stoic idea of an indifferent. Sometimes being indifferent to something may be the only sensible attitude. I for instance am indifferent to my grandson’s Aspergers, see Aspergers, Autism and Love . Sometimes being indifferent can be admirable as when a patient bears his illness with great stoicism. However, I will argue someone cannot remain indifferent to some things without causing serious damage himself as a person. What then is an indifferent? If we accept the above then a stoic only really cares about virtue and being rational and he tries to be indifferent to everything else. Stoics of course don’t deny other things such as health and even wealth might help us to flourish.  However even though these other things usually contributed to someone’s flourishing they might not do so in all circumstances. Stoics split indifferents into two types. Things such as health and wealth, which usually contributed to flourishing, are called preferred indifferents. Dispreferred indifferents are things that usually damage our flourishing such as disease or poverty.

 

The idea of a preferred indifferent appears at first sight to be nonsensical. How can someone prefer something but be indifferent to it at the same time? The answer is of course he can’t. Nonetheless it is possible to prefer something in some circumstances and be indifferent to it others. For instance, someone may prefer cream cakes normally but not if he is on a diet. I will now argue that whilst the idea of preferred indifferents may make sense when applied to cream cakes that it makes no sense when applied to the things we care about or love.

 

Let us consider a mother fleeing across the Sahara desert from persecution together with her children. Let us assume on the way one of her children dies from lack of water. A stoic would argue that this mother should be indifferent to her child’s fate. He might point out that in these circumstances the mother cannot change the fate of her child so reason dictates she should indifferent towards its fate. Of course in different circumstances she would have preferred her child to live. However I would argue such a mother cannot suddenly become indifferent to her child’s fate because she loved him and still loves him because love doesn’t suddenly die. Moreover because she loves him she identifies herself with him and someone cannot change her identity suddenly. Lastly because she loves him she makes herself vulnerable to what benefits and harms him. She feels grief. According to a stoic grief is both harmful and pointless. I have argued that love is impossible without the possibility of grief and that if we seek to limit our ability to grieve we limit our ability to love, see grief . It follows if we love something we cannot suddenly become indifferent towards it even if its circumstances change and we cannot alter these circumstances.

 

If we accept the above then stoics have a problem with love because as I have argued loving is essential to being a person. A stoic might respond that stoics can love but that this love is restricted to virtue and reason.I accept that someone who only loves virtue and reason could be a person. But I would suggest she would be a deficient or incomplete sort of person. She would lack true friends because to have friends you must love your friends see Helm (4).She might of course have friends of utility, people she uses, or friends of pleasure, people who please her, but I would not class these as true friends. A stoic might respond that she can love other things but I would argue the same problem remains. For instance if a stoic loved a childhood home in which she was happy she cannot immediately become indifferent towards it if it is burnt down..

It seems to me in trying to make themselves less vulnerable to fate stoics damage that which makes us persons; the ability to love. Persons are by their very nature vulnerable and if we try to remove this vulnerability we damage our personhood. We become soulless people somewhat akin to virtuous robots. Accepting the above would explain why a stoic who loves only virtue is a deficient or incomplete sort of person. The stoic belief that the only thing which is necessary and sufficient for someone to flourish is for her to be virtuous is wrong, for someone to flourish she must be able to love. It would appear that sometimes stoic ideas damage persons.  A stoic might respond to the above by pointing out that our turbulent emotions are equally damaging to our personhood. She might then suggest that because stoicism dampens down our turbulent emotions without the need for drugs such as anti-depressants that far from damaging our personhood stoicism actually enhances it. I have two responses to my stoic First, I would suggest that most people should be cautious about dampening down their emotions and should instead use their rationality to judge how appropriate they are and if nessary to control them. Secondly I would suggest experiencing emotions is part of being a person as we regard sociopaths as being deficient persons in some way.

In conclusion I have argued that in most circumstances the stoic’s quest to reduce or eliminate his unhappiness damages his capacity to love which in turn damages his ability to experience happiness and I wouldn’t recommend a stoic life. However for a few people who live in extremely deprived circumstances a stoic life might be the best option,

1. Harry Frankfurt, 1999, Necessity, Volition and Love, Cambridge University Press, page 114
2. Harry Frankfurt, 1988, The Importance of What We Care About. Cambridge University Press, page 91.
3. Frankfurt, 1988, page 83.
4. Bennett Helm, 2010, Love Friendship & the Self, Oxford University Press, page 122.
5. Bennett Helm, chapter 8.

Physician Assisted Suicide and the Slippery Slope Argument

Permitting physician assisted suicide for those with terminal illnesses seems to be becoming acceptable in some countries. However many remain opposed to assisted suicide and employ two main arguments against the practice. First, there are the Deists who believe it is wrong to help someone die because only God should be able to do so. I won’t address this argument in this posting. Secondly there are those who believe that permitting assisted suicide for the terminally ill would lead to a slippery slope which would over time lead to assisted suicide becoming accepted in areas in which it shouldn’t be permissible. In the past I have argued that prisoners serving life sentences and those who are going to suffer from Alzheimer’s disease have a right to assisted suicide. It might be suggested my own arguments show that assisted suicide does indeed lead to a slippery slope. In this posting I will argue that provided our underlying motivation for the introduction of assisted suicide doesn’t change that its introduction should not lead to a slippery slope.

Before proceeding we need to be clear about exactly what we mean by a slippery slope. According to the Cambridge English Dictionary a slippery slope is “a bad situation or habit that, after it has started, is likely to get very much worse.” The starting point of the slippery slope is itself bad. If we accept this definition it by no means clear that we can use a slippery slope argument when discussing assisted suicide. Let us agree that a terminally ill patient who desires to die is in a bad situation, but assisted suicide isn’t of necessity bad in this situation, even if assisted suicide can’t remedy the bad situation it might bring it to an end peacefully. I find this definition unsatisfactory and a better definition of a slippery slope might be employed. According to the Oxford Dictionary a slippery slope is “a course of action likely to lead to something bad or disastrous.” I will adopt this definition in the rest of this posting. Adopting this definition means that the starting point of the slippery slope need not be in itself bad. For instance it might be argued that allowing terminally ill patients to die peacefully is a good thing by itself, but if this slips into permitting assisted suicide for terminally ill children, adults who have mental illness, dementia patients and those who are simply tired of living, it becomes a bad thing, see Daniel Callahan in Hasting Centre's blog . A consequentialist might respond by arguing that provided the initial good outweighs the anticipated bad that assisted suicide can be justified even if it leads to a slippery slope. I won’t pursue this argument here. Instead I will argue that if motivation for permitting assisted suicide for the terminally ill remains constant then we have no need to worry about any slippery slope.

A proponent of the slippery slope argument might be prepared to accept that allowing terminally ill patients assisted suicide is in itself is a good thing but argue that this initial good is outweighed by the bad things it introduces. For instance he might argue whilst helping someone with terminal cancer die peacefully by itself is indeed a good thing, however if the slippery slope means helping grandma to die because she feels she is a burden to her family, it becomes a bad thing. The slippery slope means any good done is outweighed by the inevitable bad. I now want to question exactly what is slipping, changing. I am going to suggest what is slipping in such cases is our underlying motivation for supporting assisted suicide. Let us consider the above example. What motivates us to support assisted suicide for someone suffering from a terminal illness? Our motivation might be based on caring about the patient’s suffering or our sense of empathy caused by this suffering. Let next consider the motivations underlying grandma’s desire for assisted suicide. Grandma doesn’t want to be burden to anyone. It seems to me if we aid grandma commit assisted suicide that our motivation is different from our motivation for aiding someone with a terminal illness to die peacefully. Our motivation for helping someone with a terminal illness die with dignity is that we care about him if our motivation remains the same for grandma then because we care about her we aren’t going to help her commit suicide because we care about her. If we accede to grandma’s wish what has changed is our motivation. I will now argue that if the motivation for permitting assisted suicide for the terminally ill doesn’t change then permitting assisted suicide will not lead to a slippery slope.

One possible motivation for assisting someone to die is that we care about their suffering. We care about the suffering of someone who is suffering from a terminal illness. One response to our caring about might be to assist him to die peacefully. However there is another possible response, perhaps palliative care might permit him to end the last days of her natural life peacefully. I’m doubtful whether palliative care can always reduce suffering to an acceptable level. It seems to me that some supporters of palliative care try to derive ‘an is from an ought.’ For instance some might believe we ought not to permit assisted suicide, for various reasons, and because of this belief also come to believe that palliative care can always reduce suffering to acceptable levels. If palliative care cannot always reduce suffering then the fact that we care about someone’s suffering due to a terminal illness means we have reason to permit assisted suicide. Our motivation is based on our caring about someone suffering or feel empathy for her. I have argued that provided our motivations don’t slip opponents of assisted dying cannot appeal to the slippery slope argument.

However it might be objected the above conclusion flies in the face of the facts. Anywhere where assisted suicide has been introduced for the terminally ill has led to an expansion of the domain of assisted suicide, see for instance a report of the American Medical Association . Indeed I might be accused inconsistency by previously arguing that some prisoners serving life sentences should also have the right to assisted suicide. I now want to argue that simply expanding the domain of those who should be able to avail themselves of assisted suicide is not an example of a slippery slope. Let us recall our definition of a slippery slope as a course of action likely to lead to something bad or disastrous. If a prisoner has committed some terrible rape and murder which torments him and for which he will spend the rest of days in prison wishes to die is helping him to do so a bad or disastrous thing? Is preventing an unhappy 104 year scientist, see bioedge , from dying peacefully also bad and disastrous? If we accept that the above aren’t bad and disastrous then we can’t say they are examples of the slippery slope in action. It follows simple expansion of the domain in which assisted suicide might be applicable does not automatically lead to a slippery slope. For some course of action to be part of a slippery slope it must lead to some bad or disastrous consequences, mere expansion of the domain by itself won’t do the job. Of course extreme care must be taken to ensure that assisted suicide doesn’t lead to bad or disastrous consequences but this isn’t the same as a simple expansion of its domain. I have argued that our reason to permit assisted suicide is that we care about those suffering from terminal illness. Provided our motivation remains the same then any expansion of the domain of assisted suicide should not lead to bad and disastrous consequences and any attempt to apply a slippery slope argument to such an expansion is a failure to grasp fully the definition of a slippery slope.

I have argued that permitting assisted suicide does not lead to a slippery slope provided our motivation is one of caring. It follows that provided our motivations don’t change, don’t slip, the slippery slope argument is an ineffective argument against the permissibility of physician assisted suicide for the terminally ill.

Two Types of Pharmacological Cognitive Enhancement

It is suggested by Anders Sandberg that the use of cognitive enhancing drugs under medical supervision might achieve more overall learning and academic achievement and this is preferable to being driven into illicit use by bans, see practical ethics . In a previous posting I argued that the use of cognition enhancing drugs in examinations should be permissible subject to two conditions, see cognition enhancing drugs . In this posting I will firstly argue that there are two types of pharmacological enhancement. I will then consider such enhancement should be permissible, I will suggest that they should in some circumstances. Some of my conclusions might also apply to brain zapping, trans-crainial direct current stimulation, which might increase memory and as a result enhance cognition. I will not consider brain zapping directly.

Let us assume some drugs effectively enhances cognition. Any such drugs need to satisfy two further conditions for its use to be permissible.

1. Any cognition enhancing drugs must be safe to use without any major side effects. In certain circumstances some of these drug must be safe for long term use.
2. In certain circumstances the users of a cognition enhancing drugs must be prepared to continue using these drugs.

Commenting on Sandberg’s posting Dennis Tuchler worries about how long the effect of cognition enhancing drugs will last. He worries if cognition enhancers only work for a short time that their use will mislead employers and graduate schools about someone’s cognitive abilities. For instance let us assume someone gains a job in the diplomatic service due to her superb powers of concentration. Let us further assume that these powers are due to her taking cognitive enhancers. Lastly let us assume that once she gains this position she stops taking the enhancers and her powers of concentration fall away. In these circumstances someone else who failed to obtain the post due to the drug takers previous powers of concentration might feel he has been treated unjustly. Moreover the diplomatic service might be disappointed with the appointment. Whether Tuchler’s worries are justified depends on exactly what is involved with cognitive enhancement. Cognitive enhancement might occur in two ways. Firstly cognitive enhancement might be an ongoing process and secondly cognitive enhancement might be the end result of a process. It follows there are two types of cognitive enhancer. The first type of enhancers would result in an ongoing change in the user even after she has ceased to take the drug. Let us call such an enhancer type 1. An example of type 1 enhancer might be some drug which increases our ability to remember and what we remembered is retained even after we cease taking the enhancer. Type 1 enhancers might be likened to a scaffold round a building, the scaffolding supports the building during construction but once the building is finished there is no further need for the scaffolding and it can be removed. The second type of enhancers would require their ongoing use to be effective, let us call this type of enhancer type 2. An example of a type 2 enhancer might be some drug which helps our brains to concentrate. In the case of type 2 enhancer if use of the enhancer ceases the enhancement disappears, if the scaffolding is removed the building falls down.

Let us first consider the use of type 1 cognitive enhancers briefly. Let us assume that type 1 enhancers increase our power of memory. Sandberg believes memories enhanced by drugs will presumably endure regardless irrespective of whether the enhancer continues to be taken. Whether Sandberg’s belief is correct is open to experiment and cannot be answered by doing philosophy. However provided Sandberg’s belief is confirmed experimentally and a type 1 enhancer has no untoward side effects then philosophically there appears to be no reason why someone shouldn’t take such an enhancer. Indeed Nick Bostrom and Toby Ord’s reversal test seem to support this conclusion (1). According to this test if we accept that giving someone a drug to diminish her cognitive ability is wrong and we argue giving someone a drug to enhance her cognitive abilities is also wrong then we must be able to explain why enhancement is wrong or be accused of having a status quo bias. It appears to follow that provided a type 1 cognitive enhancer is safe that we have no reasons to prohibit the use of such an enhancer. Such a conclusion is premature and reasons might be found to support the status quo. If such an enhancer is prohibitively expensive and available only to a few due to cost then it might lead to social injustice. For instance if the use of cognition enhancing drugs was useful in the diplomatic service and these drugs were prohibitively expensive then people from disadvantaged backgrounds might be discriminated against in their attempts to join the service. The above conclusion might be amended as follows. If a type 1 cognitive enhancer is safe and not prohibitively expensive then we have no reasons to prohibit the use of such an enhancer.

Let us now examine the use of type 2 cognitive enhancers. If this type of enhancer is to be effective it must continue to be taken. Such an enhancer would affect one or more of our physiological processes and this affect would result in increased cognitive ability. Drugs that affect our physiological processes seem to require continuous use. For instance someone taking a drug to reduce his blood pressure must continue to do so. A drug which enhances someone’s ability to concentrate would be an example of a drug that has a temporary physiological affect which temporarily enhances her cognitive capabilities. It might be argued Bostrom and Ord’s reversal test gives us no reason to ban type 2 cognitive enhancers. However once again reasons might be found to support the status quo.

Perhaps the use of type 2 cognitive enhancers might mislead employers or universities about someone’s cognitive capabilities. For instance the examination grade obtained by a student taking a type 2 cognitive enhancer might not accurately reflect his cognitive abilities if he ceases taking the enhancer. However if he continues taking the enhancer then the examination should reflect his cognitive abilities in a similar way to how examinations reflect students abilities without the use of cognitive enhancers of any sort. It appears possible that the use of type 2 cognitive enhancers might be permissible subject to certain conditions. The first of these conditions is that the user of type 2 enhancers must continue taking the enhancer or else any supposed benefit will be illusory. The second condition is that the use of type 2 enhancers will not lead to social injustice.

I will deal with each of these conditions in turn. If we are to permit the use of type 2 cognitive enhancers we must be able to assure ourselves that users of these enhancers continue taking them. How might this be achieved? Let us consider this question in conjunction with safety. I will consider the question first in cases where the issue of safety is clear cut. If such an enhancer has major safety issues then its use should simply be prohibited. If such an enhancer is completely safe and the cost is reasonable then I would question if we need any such assurance. Someone with hypertension will take a safe drug to control his condition without a second thought because it benefits him and carries minimal risk. He has a reason to take the drug and no reason not to. It might be argued by analogy that much the same applies to someone taking completely safe cognitive enhancers. It seems safe to assume if someone has a reason to continue taking a cognitive enhancer and none not to that he will continue to do so. Unfortunately not all cases are so clear cut and most drugs have some side effects. In these circumstances Anders Sandberg suggestion that the use of cognitive enhancing drugs should only occur under medical supervision seems sensible. If the use of type 2 cognitive enhancers takes place under medical supervision then once again we have no reason to question their continued use. It appears to follow that provided type 2 cognitive enhancers are completely safe or only used under medical supervision that we have no reason to question their continued use.

I now want to consider whether the use of type 2 cognitive enhancers might lead to injustice? Someone opposed to cognitive enhancement might argue that the prohibitive cost of such enhancers might make them unavailable to some people leading to social injustice. I will consider this objection in two specific contexts, first jobs depending on good cognitive skill such as the diplomatic service and secondly in higher education. First let us consider type 2 cognitive enhancers in the context of jobs requiring high cognitive skills. It is in employers’ interests to provide employees with the tools to work efficiently. It seems probable that if type 2 enhancers increase efficiency in some contexts that in these contexts it is in the interests of employers to provide them for free. Of course some might not do so. If a significant number of employers do not provide type 2 cognitive enhancers for free when these enhancers have been proved to be safe and increase efficiency then some legislation might be necessary. A similar argument might be advanced with regard to higher education. Universities provide students with the tools to help them learn, libraries, lectures halls and lecturers. If type 2 cognitive enhancers are safe but too expensive for most students then provided they are a useful learning tool perhaps universities should supply them.

The above leads to some tentative conclusions which might need modifying in the light of experience. Firstly provided a type 1 cognitive enhancer is safe and not prohibitively expensive then we have no reasons to prohibit the use of such an enhancer. Secondly even if the cost of type 2 cognitive enhancers is high the use of such enhancers should be permissible in higher education and jobs requiring high cognitive skills. The permissibility of more widespread type 2 cognitive enhancers is dependent on the availability and price of these enhancers.

1. https://nickbostrom.com/ethics/statusquo.pdf