Home Health Cognitive enhancement : ethical and policy implications in international perspectives
Work on this chapter was made possible by grants from Fondecyt (1120736) and Millennium Nucleus Models of Crises (NS130017).
i. For an overview see Merkel et al.,3 Schoen-Seifert, Talbot, Opolka, and Ach,4 and Schoen-Seifert and Talbot.5
ii. The fact that currently available CE drugs have been approved as safe and effective for medical uses even in pediatric populations gives credence to this assumption.
iii. According to a recent review of articles in English, Portuguese, and Spanish from four database (LILACS, PubMed, ScienceDirect, and SciELO), from between 1990 and 2012, on the use of methylphenidate among medical students, the prevalence reaches 16% with no gender difference.43
iv. However, anecdotal evidence and my informal (obviously statistically nonrepresentative) survey of university students of other disciplines points to the conclusion that the use of modafinil and methylphenidate is fairly common, at least during exam periods.
v. However, the fact that modafinil is the drug of choice for CE in Latin America, at least in the population of medical students, is somewhat surprising. The reasons for this could be normative (e.g., lower legal penalties) or pragmatic (e.g., fewer side effects) and should be investigated in future studies.
vi. The dominant position in the academic community is critical toward the use of CE among students.44,45,10, 13,14,44,45
vii. There are different egalitarian theories of justice,46-55 and the distinction between choices and unchosen circumstances plays a central role in many of them. However, perhaps the most important contemporary theory of justice is the one offered by John Rawls. According to Rawls, society is a system based on cooperation, and the principles of justice govern the distributions of its benefits and burdens.1,56 For reasons of space, I will focus on Rawls’s principles of justice and their normative implications for enhancement in general and legitimate policy on CE in the Latin American context in particular. This is because the theory of justice formulated by John Rawls1,20 is perhaps one of the most influential positions in contemporary political theory. Rawls’s principles of justice (in its final formulation) state that (1) each person has the same indefeasible claim to a fully adequate scheme of equal basic rights and liberties, which scheme is compatible with the same scheme of liberties for all (the equal liberty principle); and (2) social and economic inequalities are to satisfy two conditions: first, they are to be attached to positions and offices open to all under conditions of fair equality of opportunity (the principle of fair equality of opportunity), and, second, they are to be of the greatest benefit to the least advantaged members of society (the difference
viii. There are many different ways of understanding the contrast between luck and agency, such as the contrast between plain and option luck, circumstance and choice, and so on. Accordingly, there are many different ways to draw the line between them.46,57-59 These are relevant discussions related to the question about what a just distribution would be, but, for reasons of space, I will not discuss this. For my normative thesis, it suffices to note that the difference between choices and unchosen circumstances is morally relevant, whatever the line between them would be, and that the circumstances that matter are social and natural ones.
ix. Rawls’s theory of justice is a hybrid theory.60 On the one hand, because of the characterization of society as a common venture for social advantages, justification of the principles of justice is based on the self-interest of individuals as society members. On the other hand, because individuals are considered free and equal with moral powers, justification is based on impartiality as a moral motivation to offer conditions of association that we can reasonably expect that others can accept. Because of the first pillar (and in line with the contractarian tradition grounded in self-i nterest) Rawls stipulates that, during their lives, contract members are comparatively equal.
x. Consider the example of dyslexia: a person with dyslexia would not be at a disadvantage in a hunter-gatherer community or a preindustrial agrarian society. However, in modern industrialized societies based on a knowledge economy, this person is disadvantaged.
xi. An issue at the core of the enhancement debate is the distinction between therapy and enhancement. The distinction can be made in different ways but is always expressed within a normative claim. Therefore, there are two associated issues: the conceptual issue and (if a reasonable distinction can be worked out) the normative claim related to it. The general idea seems to be that therapeutic technologies are a means to restore impaired human capacities to a normal level, whereas enhancement technologies are a means to raise human capacities above the normal level. A common normative claim is that the restorative aim is politically and morally valuable, but that the aim of enhancement is not. Think of the use of cognitive pharmaceuticals like methylphenidate or modafinil: if the individual using it is suffering from attention deficit hyperactivity disorder or narcolepsy, the aim is considered restorative and acceptable, all other things being equal. In contrast, when people use these drugs without the associated syndromes, “just” to improve cognitive abilities, it is considered enhancement and is therefore questionable. However, any appeal to standards of normality is debatable. These standards are always historically, socially, and technologically bounded, so it is reasonable to assert that the distinction as such is not meaningful.61 A first problem is to determine which capacities or abilities are considered properly human and to determinate the criteria of necessity or sufficiency. Even then, if a class of capacities is delineated, the level of normality still has to be established. Is this the average, the best 1%, or any other arbitrary level? The only case avoiding the problem of arbitrariness would be the creation of totally new capacities of humans by enhancement mechanisms. But this is, at least at the moment, a marginal case. The distinction rests on some questionable (often naturalistic) premises about what is naturally appropriate (or normal) to a human being. A common bypass strategy is to link the distinction between restoration and enhancement to the distinction between disease and health. But because of the difficulty to provide an exact definition of “disease” and “health,”62 this strategy reproduces similar problems as the distinction between enhancement and restoration. In his influential definition, Boorse63-65 links “health” to statistical normal functioning for a given species. There are similar distinctions in ethical debates.66,67,21,23 Not without reason, the claimed non-normativity of Boorse’s conceptual distinction is questioned.68 It is grounded in normative decisions about what normal human functions are. Despite these difficulties, the distinction between disease and health is productive. Everyone has some intuitive, if vague idea about this distinction, and, more importantly, about its centrality related to the allocation of scarce (medical) resources.32
xii. The opposite is not necessarily true: individual liberty doesn’t extend necessarily to the use of these technologies. This asymmetry is based on the possible consequences of the extended use of these technologies on the liberty of other individuals. I’ll examine this point in the next section.
xiii. Probably we have good reasons in the case of some nonpharmacological enhancement strategies as well, like nutrition, physical exercise, sleep, meditation, mnemonic strategies, and so on. There is some evidence that these strategies could be even more effective than pharmacological enhancement.69
xiv. For a similar, yet distinct, discussion about policy options in case of amphetamine, methylphenidate, and CE drugs see Dubljevic.42,70
xv. Obviously, the social components of the “ambition” that luck-egalitarianism considers as part of an egalitarian theory58 are outside the scope of this policy.
xvi. For an argument in favor of moderate enhancement grounded on compensation, see Gesang.71: ch 2
xvii. For this line of argument against enhancement, see Sandel.72
xviii. These could perhaps be dealt with at lower level of regulation (e.g., university rules).
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