In bioethics, technologies are often distinguished as therapeutic or enhancing. On one hand, therapies consist of most biomedical technologies we’re familiar with: bandaids, open-heart surgery, antibiotics, and so on. Enhancements, on the other hand, are slightly rarer in practice—we might include something like steroids for athletic training—and are mostly the stuff of science-fiction, though they become more real everyday: think brain implants, powered prosthetics, and gene editing. Being able to distinguish between these two categories is supposed to help us ethically evaluate technology use—it’s OK to use therapeutic technologies, it’s wrong to use enhancements. However, I suspect the distinction does not do as much work as we might imagine.
Though they ultimately problematize these terms, the President’s Council on Bioethics, organized in 2001 to advise the Bush administration regarding advances in biomedical technology, offer helpful definitions in their treatment of the subject:
“Therapy” … is the use of biotechnical power to treat individuals with known diseases, disabilities, or impairments, in an attempt to restore them to a normal state of health and fitness. “Enhancement,” by contrast, is the directed use of biotechnical power to alter, by direct intervention, not disease processes but the “normal” workings of the human body and psyche, to augment or improve their native capacities and performances.
This way of defining enhancements in contrast with therapies is helpful for making moral sense of something like Adderall. For most, the use of amphetamines to assist concentration for individuals with ADHD is unproblematic, while their use for increased cognitive performance by those without attention deficits seems intuitively wrong. In such a case, the therapy-enhancement distinction provides ethical clarity.
Yet, how to draw the line between therapy and enhancement is not always clear. Adderall already demonstrates that technologies cannot be categorized as inherently therapeutic or enhancing but depend, instead, on their use. Or, take for example the quintessential enhancement goal for “radical life extension.” If a man suffers from a stroke, and doctors use some cutting-edge procedure to heal him, most would consider this a form of therapy. There was a problem and they fixed it. If the next month the same man develops a rare form of cancer, and the doctors heal him once again with a newly developed treatment: still therapy. If in a week, the man is found to have heart disease, and the doctors offer him an experimental new drug, is that not still therapy? But if this continues on indefinitely, for any given disease or disorder, death would be perpetually delayed and the man would experience, in essence, radical life extension. The therapy becomes enhancement.
Additional confusion enters the discussion over the term “normal.” It is unclear how to define such a term (which the President’s Council recognizes with their scare quotes). Is normalcy relative to the individual using the technology or to humanity as a whole? If the individual is the standard, cosmetic surgery would qualify as a subjective enhancement, increasing a person’s attractiveness beyond their normal appearance. Eye surgery might be therapeutic for an older individual—their sight was poor and now it is better—but it could be construed as an enhancement if normal refers to what is common for most people at that age. If normal is species-relative, then we have to further ask if we are looking at the average, the standard deviation from the median, or the upper limits of what is humanly possible—achieved or theoretical? Such appeals to the typical or normal are both slippery and maybe even morally suspect.
Furthermore, what does it mean to alter the human body, to “augment or improve their native capacities and performances”? There are certainly some obvious examples of bio-enhancement—synthetic blood, brain chips, titanium endoskeletons—but for each of those, there is a more ambiguous case. Consider an enhancement that certainly improves human performance but has minimal effect on the body: the automobile. Cars unquestionably augment what humans can do, allowing for speedy travel and the ability to cross great distances, but they can also be easily distinguished from our physical form. Further along the spectrum are enhancements that slowly shape our bodies and minds—things like shovels and watches. Over time, they can dramatically transform our morphology or our perception of the world, but they are still easily distinguished from the human form. And then there is the ambiguity of something like whole-brain emulation, allowing for uploaded consciousness. If a person lies on a bed, with diodes connecting them to a computer where they live out their life in a virtual reality, this certainly seems to affect their bodily existence even as it leaves their anatomy untouched.
Borrowing from my teacher, Neil Messer, it might be more helpful to think of therapy as that which treats disease, and enhancement as that which overcomes limits outside of disease. One interesting advantage of this definition is that therapy and enhancement are no longer zero-sum categories; they’re concerned with two related but different things: disease and limits. Now, “limits” still function here much in the same way “normal” functioned previously, but the the difference is in how the word helps bring into focus the subjective element of our relation to these technologies. In fact, both disease and limits, to varying extents, have a subjective component. Even as disease is clearly rooted in empirical reality, humans are the ones who decide and discern which bodily phenomena count as disease. (Take, for example, aging, pregnancy, or grief—all experiences that share the characteristics of disease.)
To an even greater extent, I want to suggest that limits, in addition to being broader than disease, are a deeply subjective category, in this context referring to elements of our existence that we find disagreeable. Any number of things can be construed as limits (which could, in another context, be described as an allowance or ability). Our limits include our susceptibility to the flu as well as our susceptibility to sickness in general; they include our limited lifespans and our ability to forget; our need for constant air, food, water, and even social interaction. They also include our inability to travel instantaneously or to communicate flawlessly or the fact that I cannot have chocolate cake whenever I want. Some of our limits are mere inconveniences, and others are the most tragic traits of our species.
Outside of the context of disease, the technologies we deploy to push back against limits are called enhancements. What we have in mind are technological innovations meant to improve something about already sufficiently functioning aspects of our lives. By this definition, cars and computers are enhancements and only become mere “tools” when the improvement they provide becomes expected for daily life (and is no longer thought of as a limit). For the foreseeable future, synthetic blood and ear implants that translate in real-time are enhancements.
Our moral evaluation of these enhancements are themselves proportional to our moral evaluation of the limits they counter. Some of our natural limits we classify as evil, and some of those evil limits we classify as disease. Some limits may be a problem—something inconvenient—but we would hesitate to call them evil. And even some limits, while we individually do not enjoy them, we label as necessary, human, and even good. Without a doubt, our expectations play a major role in this—what do we expect to suffer in life?—but in any case, we have some idea of limits we ought to counter and those we ought to embrace. Such distinguishing is yet another example of something requiring discernment. In the same way that humans discern which bodily phenomena classify as disease within their moral framework, so Christians also discern which limits are integral to the human condition, often with aging and the inevitability of death chief among these.
In terms of ambiguity, this way of defining therapy and enhancements, indexed to concepts of disease and limitation, is not a significant improvement over the President’s Council definition and a focus on normal human capacities—the lines are still blurry. But a focus on limits does foreground what I take to be the real importance of terms like therapy and enhancement: that they communicate our internal assessment of how given technologies effect us. Speaking of a technology as an enhancement signals that it holds a particular relation to our human nature, and moreover, the morality of that technology is tied up in the value of the particular limits it counteracts. That is, ethical assessment of a technology does not come by properly categorizing it as enhancement or therapy—to assess a technology is to assess how it affects our forms of life.