Therapy and Enhancement meeting the need for a distinction without making it

1. Therapy and Enhancementmeeting the need for a distinction without making it Christian Munthe Dept. of Philosophy, Göteborgs University Munthe C, The Morality of Precaution: Interpreting, Justifying and Applying the Precautionary Principle. (unpublished)

2. The framing of discussions of gene technology (GT) in bioethics • Visions of fantastic achievements (VFA) • Debate: what could be bad with those? • Enthusiasts (post/trans-humanists, futurists, followers of juche) • Negativists (humanists, pessimists, natural law believers…) • Sceptics (Can’t say before I know much more, especially if we want to be able to address practical issues of policy and clinical practice) => Discussion needs to be framed in termes of risks, chances and their evaluation, rather than whether or not certain outcomes would or would not be acceptable ”in principle”). => Me! • Therapy - Enhancement (T-E) • A negativist strategy for allowing some GT while excluding (alleged) excesses • Enthusist reducio strategy against negativists • Debate: so, what’s so bad about enhancement, then? • Enthusiasts: (VFA negativists: natural order, ethos of medicine, etc.) • Negativists: (VFA enthusiasts: nature and ethoses don’t matter morally, all that matters is magnitude of benefits and harms) • Sceptics (Can’t say. The distinction is incomprehensible and to the extent that it is not, it is doesn’t help with solving the practical problems of whether or not to allow/fund/apply particular procedures). • I’m a sceptic on both counts => new framing in terms of the ethics of risks

3. Reasons for a distinction • Responsible procedures (risk-possible benefit) • Priorities (risk-possible benefit) • The (generic) distinction: • Absolute limit: different types of benefits • It is irresponsible (for health care) to engage in enhancement • Therapy should always be given priority • Criticism • No clear/plausible typology of benefits • The importance of benefits only depends on magnitude • So go for the greatest arm-benefit ratio! • Risk-chance: repetition in terms of expected utility • Conflict • Equal benefits are morally on a par if the risks are similar • The original reasons defeated: • Mending a boken arm - transplanting a third functional arm. • Extending life expectancy to 160 years - preventing early death today • Transhumanism, Enhancement enthusiasm, etc.

4. My idea • Denying an absolute limit is compatible with a comparative (gradual and option-sensitive) difference between the moral importance of equal risk-chance ratios. • (0.5 x -1 / 0.5 x 1) vs. (0.5 x -10.000 / 0.5 x 10.000) • Some elements that may be employed: • Quality of evidence matters: poor quality is a cost (e.g., uncertainty) • Risks may be more important than chances even if they have equal magnitude. • Progressively increasing moral importance of risks (compared to chances) • Comparison with/relativisation to an idea about a decent risk-chance mix. When are we ”OK”? • Also other ideas may do the job… a prioroty view in risk terms… • Abandoning the T-E distinction does not have to imply abandonment of the original reasons for it. • If one wants, one may baptise permissible (in a certain context) procedures as ”therapy” and impermissible ones as ”enhancement” (but what’s the point?) • The distinction becomes relative to context (Global - National) • The distinction may not track ”intuitive” ideas very well