The presumption against direct manipulation

If we say that itbecomes treatment as soon as Billy’s IQ falls below the normal range,then, it seems, it is not the disease conception of the distinction towhich we are appealing, but th

t h e t r e a t m e n t / e n h a n c e m e n t d i s t i n c t i o n

In the last chapter, we set out the objections that seem to underlie thepresumption in favor of traditional means of changing minds (here-after, ‘‘the presumption’’) In this chapter we shall consider theseobjections in detail Before we begin treating them, however, we need

to consider another, more general, question, one that cuts across all theother objections and across a range of possible neurological interven-tions Many people – laypeople, philosophers, bioethicists and neu-roscientists – have importantly different responses to actual andpotential neuroscientific (as well as medical) interventions, dependingupon what they are being used for Interventions to treat diseases andimpairments are regarded as significantly more permissible (perhapseven obligatory) than interventions aimed at enhancing normal capa-cities Treating disease is generally regarded as an intrinsicallyworthwhile activity, and we are therefore under a (possibly defeasible)obligation to engage in it, but enhancing already normal capacities is aluxury, which is at best permissible, and not obligatory, and at worstimpermissible Different thinkers make different uses of the treat-ment/enhancement distinction For some, it marks the differencebetween the kinds of medical interventions which it is incumbentupon the state to provide, and the kinds of interventions which canpermissibly be bought and sold, but need not be provided as a matter ofjustice; for others, it marks the difference between interventionswhich are permissible, and those which ought to be banned Despitethese disagreements, there is a broad consensus that the treatment/enhancement distinction marks a difference that is morally significant

The traditional home of the treatment/enhancement tion is medical ethics However, it seems just as pertinent to the field

distinc-of neuroethics Suppose that the presumption against direct ulation can be sustained In that case, these manipulations are to beavoided, whenever possible; they can be used only when they give usthe sole, or the sole practicable, means of treating conditions thatimpose significant suffering on patients (and those close to them) Inthat case, it follows quite directly that the use of direct manipula-tions to enhance already normal capacities will always be imper-missible Moreover, if the treatment/enhancement distinction can besustained, it provides us with additional reasons to doubt the per-missibility of enhancements, over and above that provided by thepresumption: enhancements constitute a kind of cheating, andwould exacerbate existing inequalities

manip-e n h a n c manip-e m manip-e n t s a s c h manip-e a t i n g

Suppose Billy and Beth are both scheduled to sit an importantexamination Both are talented students; both are hardworkingand conscientious Both are looking for that extra edge in theexam, since they know that performing well on it will open doors

to better employment opportunities Both therefore avail selves of the full range of means traditionally employed to achievesuccess They both sit practice examinations, look at past papersand talk to people who have already been through the process,seeking advice and helpful hints But Beth goes further: she takesRitalin, which is widely used by college students to enhance con-centration and to boost performance on problem-solving tasks(Farah 2002; Farah and Wolpe 2004) Her performance is corre-spondingly better than she would have achieved without the drug.Her final score is a couple of precious percentage marks higherthan Billy’s, and she has pick of the rewards that come from suc-cess at the exam Billy is normally a gracious loser, but not thistime When he learns that Beth’s performance was drug-enhanced,

them-he feels cthem-heated

Drugs and other biological interventions that enhance sportingperformance have received a great deal of attention from ethicists(Mottram2003; Savulescu et al 2004) But the problems that arisefrom the use of enhancements of the mind can be expected soon todwarf those arising from their use on the sports field With our agingpopulations, there is a huge potential market for drugs which slow oreven reverse the loss of memory and cognitive function typical ofdementia Of course, few people would object to such treatments of atragic disease But these same drugs may prove useful in enhancingthe memories of normal adults (Farah 2002; Glannon 2006a).Research into drugs that enhance learning in different ways is alsowell advanced The adult brain learns at a slower rate than thechild’s, and part of the reason seems to be that the child’s is moreplastic Some researchers are therefore investigating ways of enhan-cing learning by increasing neural plasticity One promising line ofwork explores the role of gamma-aminobutyric acid (GABA) in nor-mal learning GABA is a neurotransmitter that plays an inhibitoryrole in the human brain; in normal skill-acquisition, GABA levelsfall, allowing the brain to rewire itself, and thus lay down the path-ways that will underlie the skill Ziemann and his colleagues (2001)have published preliminary results, from studies of human subjects,suggesting that deliberately manipulating GABA levels may increaseplasticity, and therefore enhance skill acquisition Ziemann et al.suggest that this might provide us with a therapy to aid the recovery

of patients who have suffered some kind of neurological insult But –

if the technique proves safe and effective – it may find a biggermarket among normal people looking for that extra edge, or a shortcut to new skills and knowledge (Gazzaniga2005)

Antidepressants are already sometimes used to enhance thelives of individuals who do not meet criteria for any psychiatricdisorder Of course, most people who take such medications look tothem for a boost in mood, but, whether as an intended effect orincidentally, antidepressants may also aid them in achieving goals intheir work, study and relationships Small-scale studies of the effects

of SSRIs on normal subjects indicate that they make people morecooperative and less critical of others (Knutson et al 1998) – traitswhich are likely to be attractive to employers Other studies haveconfirmed that healthy subjects given antidepressants show greatersocial affiliative behavior, associated, perhaps paradoxically, with adecrease in submissiveness (Tse and Bond2002;2003) In many ways,antidepressants seem tailor-made for achieving the personality pro-file stereotypically associated with success And there is evidence(most of it anecdotal) that people taking antidepressants are moresuccessful (Kramer1993).

But it is easy to see why many people would begrudge themsuccess achieved by pharmaceutical means Just as it is widelyregarded to be cheating to use steroids to achieve athletic success, so

we might regard the use of psychopharmaceuticals to enhancememory or concentration as a kind of fraud Here’s one way of jus-tifying this intuition: it is a deeply held principle of modern Westernsocieties that opportunities ought to be distributed according tomerit Thus, jobs ought to be open to talent, not reserved for themembers of some hereditary caste, or for the members of a particularrace or gender Rewards should be deserved But Beth does notdeserve her greater success She worked hard, true, and hard work isdeserving of praise She is also talented But Billy is just as talented,and worked just as hard He therefore deserves as much success asdoes Beth Beth achieved greater success, and perhaps she did itwithin the rules But she contravened the spirit of the rules Shecheated

Note that this objection to the use of direct interventions islimited only to their use as enhancements Were Beth suffering from

a disease that prevented her from using her talents, few people wouldbegrudge her the use of psychopharmaceuticals, or whatever thetreatment might be Rather than constituting cheating, her use ofpsychopharmaceuticals would simply correct for her disadvantage, inthe same manner as, say, eyeglasses correct for short-sightedness It

is because Beth uses the drugs to raise herself above her already

normal, or better than normal, level that Billy feels that she hascheated The same point applies to our next objection, the objectionfrom inequality.

i n e q u a l i t y

Enhancements of the mind like those we have just reviewed arealready available and may become commonplace But it is extremelyunlikely that they will be available to everyone who wants themanytime soon The cost of pharmaceuticals puts them beyond thereach of the literally billions of people who live in extreme poverty,mainly in developing countries Indeed, those drugs which must betaken continuously if mental function is to remain enhanced (such asRitalin and SSRIs) are out of the financial reach even of much of thepopulation of the developed world, at least in the absence of gov-ernment subsidy Other possible neurological enhancement tech-nologies, such as the portable transcranial magnetic stimulationdevice envisaged by Allan Snyder (Osborne2003), as a way to bringout the savant-like abilities he and his colleagues believe to be latent

in us all (Snyder et al 2003), would probably prove even moreexpensive So the new enhancements will be available, in practice,only to the wealthier members of our society

But these people are already better off than average, and theiradvantages extend to their minds They may not be more intelligentthan their fellow citizens, but they are better placed to develop theirintelligence to the full They send their children to the best schools,where they receive the best education; private tutoring is available tothem if it is needed More importantly, perhaps, they are brought up

in an environment in which thought is respected and in whichintellectual achievement is seen as a genuine possibility, a possibi-lity for them in particular It is not a strange world, from which theyare alienated or to which they do not think they can ever belong.Their parents are professionals – lawyers, physicians, academics –and the world of professional achievement beckons to them More-over, they have better health care and better nutrition, both of which

are conducive to higher intelligence Birth weight, which reflectsthe nutritional and health status of the mother, is correlated with

IQ, even when we restrict our attention to the normal range ofweights, thereby excluding children born into extreme poverty(Matte et al.2001)

Higher socio-economic status is already associated with higherintelligence (Hunt1995) But if neurological enhancements becomewidely available, we can expect the gap to grow ever greater, bothbetween countries, and between the wealthy and less wealthy citi-zens within countries Since intelligence, in turn, is a key to pros-perity and therefore further wealth, neurological enhancements arelikely to speed up the rate at which a circle, which is already inmotion, turns: enhancement leads to greater intelligence and suc-cess, which leads to wealth which enables further enhancement.Meanwhile, the less well-off languish in their unenhanced state.Now, there are several reasons to worry about the exacerbatedinequalities that these enhancements might produce First, theymight (further) diminish feelings of social solidarity The rich maynot feel that they are in the same boat as the poor, so different arethey from one another, and this might translate into a reducedwillingness to contribute to the general welfare They might demand

a lowering of tax rates, failing which they might move their assetsoffshore They might refuse to contribute to campaigns which aim

to alleviate famine and the effects of natural disasters around theworld They may regard the poor as natural slaves (in Aristotle’sphrase), who are born to serve their needs Second, many peopleregard inequality, at least undeserved inequality, as intrinsicallyundesirable The wealthy have been lucky: lucky in their genes,lucky in the environment into which they were born and lucky, inour scenario, that they are able to translate their existing advantagesinto neurological enhancements Since we do not deserve our luck,

we do not deserve the extra advantages it brings; correspondingly, thepoor do not deserve their lower status and their lower standard

of living

p r o b i n g t h e d i s t i n c t i o n

Though most writers on the topic are convinced that a defensibletreatment/enhancement distinction can be drawn, there is littleagreement as to how best to draw it There are two main approaches:the distinction can be defended by way of the contrast between dis-ease and non-disease states, or by reference to the notion of species-typical functioning (Jeungst 1998) I shall argue that both theseapproaches have insurmountable difficulties, and that the treatment/enhancement distinction ought to be abandoned It cannot, I shallsuggest, do the work that writers on the topic hope for it: it cannotprovide us with an independent standard to which we can appeal tosettle moral arguments Instead, it is already (at best) a thoroughlymoralized standard We ought, therefore, to recognize that it is amoralized standard, and assess it on moral grounds

Treatment, as the word suggests, might be defined as medicalintervention aimed at curing, reversing or halting the progression

of diseases and disabilities On this view, an intervention wouldcount as an enhancement only if it is not aimed at treating disease.Unfortunately, the distinction between disease and other undesir-able conditions is itself rather unclear We might hope to define

‘‘disease’’ in terms of alterations of somatic function as a result ofnon-endogenous elements, where an endogenous element is any-thing specified in our genome But – quite apart from the problem, towhich we shall return, of making sense of the notion of somethingbeing specified in our genome – this won’t do Normal functioning isitself dependent upon a range of external elements, from the bacteriawhich help our digestion and which help maintain the health of ourskin and eyes, to the nutrients we need to absorb from the environ-ment in order to remain alive Now, suppose that Beth is moreintelligent than Billy because her ‘‘gut flora’’ enables her to absorbnutrients from food more efficiently, and this has given her adevelopmental advantage over him Does Billy have a disease? If hedoes, it is caused by the lack of an external (external, that is, to hisgenome) element Perhaps Billy’s intelligence is within the normal

range, though lower than it might have been In that case, is medicalintervention an enhancement, not a treatment? If we say that itbecomes treatment as soon as Billy’s IQ falls below the normal range,then, it seems, it is not the disease conception of the distinction towhich we are appealing, but the species-typical account.

Part of the problem for the disease-based approach to thetreatment/enhancement distinction is that the concepts of diseaseand disability are far more malleable than proponents are willing torecognize A ‘‘disability’’ might be regarded as any impairment offunctioning which departs far enough from the social norm Whatcounts as a disability is therefore relative to the norm: dyslexia is adisability only in literate societies (Buchanan et al.2000), and beingtone deaf is a disability only in societies which speak a tonal lan-guage Of course, it might be replied that we are only interested inthe extent to which an impairment counts as a disability here andnow, and that therefore the fact that an impairment would or wouldnot be a disability elsewhere (that it might even be an advantage) isirrelevant But to appeal to departure from the norm, here and now,

is to give up the disease-based defence of the ment distinction in favor of the species-typical conception Alter-natively, we can appeal to our intuitions about disease to defend thedistinction But the treatment/enhancement distinction is supposed

treatment/enhance-to give us a means of evaluating whether a proposed interventionaimed at correcting for an impairment is permissible (or obligatory,

or ought to be state-funded, depending upon the account) or not If

we appeal to the notion of disease to defend the distinction, andthen appeal to intuition to defend the conception of disease weprefer, we implicitly appeal to intuition to defend the distinction –and in that case we have abandoned the claim that the distinctionoffers us an independent test of our intuitions In that case, it islikely that it is in fact our moral judgments about the permissibility

of intervention that are driving our intuitions about the distinction,rather than the other way round Indeed, I suspect that that’s pre-cisely the case

There is another, deeper, problem with drawing the distinctionbetween treatment and enhancement on the basis of the diseasemodel But the problem – that in fact no sense can be made of oneterm of the contrast, and therefore of the contrast itself – obviouslygeneralizes beyond the disease approach I shall postpone discussion

of it until we have the second major approach to the distinctionfirmly before us I turn now to the second popular approach to dis-tinguishing between treatment and enhancement

The species-typical functioning approach is primarily ciated with the work of Norman Daniels (1985; Buchanan et al

asso-2000) Daniels argues that treatment is medical intervention aimed

at restoring the patient to normal functioning In this approach, as inthe first, disease is invoked, but it does not play a foundational role.Instead, what counts as disease or disability is defined by reference tonormal or species-typical functioning Treatment is medical inter-vention aimed at disease or disability, where disease or disability isadverse departure from normal functioning An attractive element ofthis account of the distinction is that it gives us a natural explanation

of why enhancement is less important, from a moral point of view,than treatment Treatment aims to restore individuals to normalfunctioning, not because the normal is somehow intrinsically good

in itself, but because normal functioning is necessary for equalopportunity In Daniels’ account of the aims of a just health system,health care is designed to restore and maintain individual’s access totheir share of ‘‘the normal range of opportunities (or plans of life)reasonable people would choose in a given society’’ (Buchanan et al

2000: 122) Since equal opportunity is (extremely plausibly) itself avaluable good, worth protecting, restoring the ability of individuals

to pursue it is itself worthwhile

The normal functioning view aims to restore individuals totheir baseline capacity, the capacity that is naturally theirs Diseasesare departures from this state; so are impairments due to past unjustsocial practices and discrimination But simply being less intelligentthan average is not, on this account, a disease or impairment that we

are morally obliged to treat My lack of intelligence, or of good looks,

or athletic ability, is simply the result of my bad luck in the naturallottery, and such bad luck does not impose any obligations on others

We ought to restore people to the natural baseline that is theirs, invirtue, presumably, of their genetic endowment Raising them abovethat baseline is not treatment, but enhancement

Obviously, this view depends upon our being able to identify anatural (or ‘‘natural,’’ as Buchanan et al.2000would have it) baselinefrom which disease or disability is a departure The problem withthis approach is simply that we can’t do this The very idea is bio-logical nonsense To show this, it is necessary to make a shortexcursion into the way in which genes function in building pheno-types – the observable characteristics of organisms

All commentators, including Buchanan et al (2000) reject theidea of genetic determinism That is, we all now recognize that ourgenome does not simply encode our traits The relationship betweenpossession of a gene and the development of a phenotypic trait is acomplex and mediated one To be sure, there are some genes andgene-complexes that lead to predictable, usually adverse, con-sequences across the range of accessible environments But mostgenes, and pretty much all genes for traits that are within the normalrange, do not work like that Instead, their phenotypic effects are theresult of the way they interact with the environment and with eachother

Despite the fact that everyone rejects determinism and acceptsinteractionism, many people continue to speak of the genome as a

‘‘blueprint,’’ which ‘‘encodes’’ traits; and about the natural baseline

of capacities which is ours in virtue of our genome None of theseideas make any sense, in the light of interactionism

The effect of any particular gene on the phenotype (leavingaside those that cause the relatively few congenital impairments,such as cystic fibrosis and Down’s syndrome, which produce adverseeffects in all accessible environments – though even they merelycomplicate the picture, they do not falsify it) is the product of the

way it interacts with the environment external to it, where thatenvironment includes other genes Not only do genes not have anydeterminate impact outside that environment, we cannot even assign

to them a tendency outside a particular environment The geneassociated with high intelligence in environment X may be a genethat is associated with low intelligence in environment Y – and thetwo environments may not be all that different In more technicalterms, the norm of reaction for a given genotype is never additive Anorm of reaction is the graph representing the variation of a givenphenotypic trait as a function of environmental variation Forinstance, a norm of reaction might plot the predicted adult height of

a plant (with its genotype held fixed) as a function of one mental variable such as sunlight, or nitrogen in the soil The norm ofreaction is additive when the relationship between the environ-mental variable and the trait is linear: an increase in the variablecausing a proportional increase or decrease in the variable and adecrease having the opposite effect It is non-additive if the rela-tionship is not so straightforward: if, for instance, increasing theamount of sunlight increases the height of the plant up to a certainpoint, beyond which further increases actually decrease height Allnorms of reaction studied so far have been non-additive, and theoverwhelming likelihood is that this will hold true for all possiblenorms of reaction (including the norms of reaction for those con-genital traits mentioned above) (Levy2004)

environ-Thus, there is no natural (or even ‘‘natural’’) baseline againstwhich we can measure departures Because phenotypic traits vary as

a function of the way the environment is structured, because they donot have any determinate effect, not even a tendency, outside aparticular environment, talk of what a person’s capacities wouldhave been in the absence of a disease is either entirely empty, or itpresupposes a determinate environment If we are presupposing

an environment, though, then it is permissible to ask why thatenvironment Suppose that Jorge and Joaquin both apply for a job,and are given a battery of tests to measure their intelligence and

problem-solving abilities Joaquin outperforms Jorge, and is offeredthe job In Daniels’ account, Jorge has no legitimate complaint, if thedifference between their achievement is not due to a history of unjustdiscrimination Let’s assume that’s the case; let’s assume that nei-ther belongs to a group that is discriminated against, either now or inthe recent past Nevertheless, suppose (realistically) that Joaquin’sadvantages – his better education and health care – are partlyresponsible for his higher achievement What reason do we have tosay that Jorge’s level of achievement reflects a natural baseline, giventhat in a range of accessible environments he would have achievedmore (and in a further range he would have achieved less)? Why takethisenvironment as natural?

One possible move at this point would be to abandon the claimthat the environment in question is natural, and therefore the cor-relative claim that the baseline is natural We could instead look for anormatively defined baseline: we might say that the capacities that

an individual deserves are those that they would possess in a justenvironment Indeed, something like this kind of view may accountfor whatever surface plausibility Daniels’ definition of the baselinepossesses In a Nozickian (1974) account of justice in distribution,any distribution of assets, no matter how unequal, is just so long asthe history of acquisition of assets is not unjust, where injustice inacquisition is defined essentially in terms of theft, fraud and so on.This view has the counterintuitive implication that gross inequality,indeed absolute poverty, is not unjust so long as it is inherited pov-erty (and the poverty cannot be traced back to fraud, theft or othercrimes) Daniels’ definition of the baseline, according to which onlycertain classes of environmental influences count as illegitimate,commits him to an analogous, though less extreme, view of justice indistribution of traits So long as there was no injustice, as Danielsdefines injustice, in the history of acquisition of these traits, we are

to take their distribution as just, even though there are possibleenvironments in which the distribution of traits would have beenradically different In other words, Daniels is committed to regarding

the actual environment as just, or at least just enough This is anormative assessment: environments are regarded as just or unjustnot on the basis of their ‘‘naturalness,’’ but on the basis of the dis-tribution of traits.

Now, this is a coherent view Note, however, that like thedisease-based account of the treatment/enhancement distinction,this view does not give us what defenders of the distinction wantfrom it: an independent (because natural and non-normative) stan-dard to which we can appeal in making moral judgments Instead, it

is itself a normative view through and through If that is a weakness,however, from the point of view of those who are looking for anindependent standard, it is also a strength from another point ofview Once we have the normative commitments of the view on thetable, we can begin to assess them on normative grounds We canbegin the debate over whether gross inequality in capacities is itselfunjust, when neither those who are better off nor those who areworse off have done anything to deserve their relative abilities, orwhether such inequalities are only unjust when they are the product

of a grossly unjust history As I have argued elsewhere against Nozick(Levy2002a), given that no one deserves the conditions into whichthey are born, no one deserves their relative advantages, and for thatreason we have a (ceteris paribus) obligation to correct for grossinequality In any case, once we see that the treatment/enhancementdistinction rests upon a normative base, we ought to abandon it, as afocus for discussion and as a reference point in debate, and insteaddirect our attention to the plausibility of the normative commit-ments upon which it rests

In other words, in assessing the suggested baseline againstwhich to judge whether an intervention is an enhancement or atreatment, we need to ask ourselves whether the causes of thecapacities in question are themselves just, as well as whether theresulting distribution of capacities is ethically permissible Since ourtopic is cognitive enhancement, it is worth spending a little timereviewing the ways in which social and political choices influence

the distribution of cognitive capacities We have already glimpsedsome of the ways in which our environmental transformations altercognition by offloading it onto external props, in the section on theextended mind Here I shall simply mention some of the more pro-saic environmental factors which are relevant to intelligence.

Measured intelligence has risen consistently over the pastcentury, across the world The increase has varied, with some groupsshowing only relatively modest gains of around three points perdecade, while others increased at twice the rate But the effect(known as the Flynn effect, after the political scientist who firstdocumented it (Flynn 1994)) is nearly ubiquitous Now, it is stillsomewhat mysterious what underlies these gains, but we canexclude genetic changes at once There may be selection pressures forincreased intelligence, but the effect is far greater than such pressurescould explain (given the slow reproduction rate of our species) Threefactors have plausibly been proposed as explaining the rise: betternutrition, better education and alterations in the environment(Neisser1997) We know, from studies of animal models, that simplyenriching the environment in which the young are raised has a sig-nificant impact upon problem-solving abilities Rats raised in anenriched environment perform significantly better at maze naviga-tion tasks than rats raised in an impoverished environment (impo-verished, that is, in terms of stimuli like toys and nooks to explore);rats from strains bred to be ‘‘maze dull’’ outperform rats bred to be

‘‘maze bright’’ if the former are raised in an enriched environmentwhile the latter are not (Kaplan2000)

Holding that the current distribution of resources in the world,

or within one country, represents a natural baseline against which tomeasure departures is arbitrary and morally unjustifiable We can besure that if the distribution of resources were altered, some indivi-duals would do better, and in some cases far better, than they do now(and some worse) We do not know if there is an optimal distribution

of resources or an optimal environment for increasing people’s nitive abilities, but we do have every reason to think that we are

cog-nowhere near to achieving such a distribution (on the contrary; there

is evidence that in some places IQ has fallen marginally, and thatenvironmental changes are to blame (Teasedale and Owen2005)) It

is therefore morally inappropriate to take any current distribution as

a baseline, as well as scientifically unjustifiable

The inability to set a baseline against which to measure normalfunctioning will obviously prove fatal to an account like Daniels’,but its effects spread beyond this particular approach to the treat-ment/enhancement distinction In fact, without a baseline to appeal

to, all conceptions of enhancement, at least all which look to thedistinction for an independent test of permissibility, are in trouble.Medical interventions that are commonly regarded as treatments, aswell as those that are regarded as enhancements, increase the capa-city or well-being of patients In that, minimal, sense, they are allenhancements (when they are successful) For a very wide range ofinterventions, it is true to say that the subject would be better off as aresult than they would be in their absence This counterfactual claimcan’t pick out enhancements, because it is true of too wide a range ofinterventions My intelligence might be enhanced by, say, tran-scranial magnetic stimulation, in the sense that I might becomecapable of savant-like feats of which I am currently incapable But

my intelligence can also be enhanced by learning: if I devote myself

to a program of arithmetical tricks, I can no doubt improve myability, perhaps remarkably (if I am prepared to spend enough timeand energy on the project)

We could, of course, always decide to set a baseline by reference

to non-moral criteria We might, for instance, choose one standarddeviation below the average (or the mean, or the median) as thebaseline: anyone with a capacity or characteristic falling below thisthreshold would have the right to have it raised But if we were to do

so, we would be engaged in a deliberate act of choice, and shouldsee ourselves as such The grounds for the choice would not besolely natural; we would not have identified an Archimedean pointwhich really separates obligatory treatment from supererogatory or

impermissible enhancement The grounds for our choice wouldinstead be moral and political These are, I suggest, precisely the rightgrounds upon which we should be making these choices; indeed, as

I have argued, they are probably the grounds upon which, implicitly,

we currently divide interventions into ‘‘treatments’’ and ments.’’ It may be that instead of setting a baseline, it would be better

‘‘enhance-to ask ourselves whether, in the absence of intervention (and holdingthe rest of the environment fixed) the impairment in question issignificant enough to warrant the intervention Once we see our-selves as making a moral choice, the debate over the right groundsfor this choice can begin in earnest; at present the attempt toidentify an illusory baseline merely obscures the genuine grounds forintervention

Abandoning the treatment/enhancement distinction in favour

of an importance of intervention test will also allow us to capturethe undoubted fact that many interventions which intuitively fall onthe enhancement side of the divide are far more urgent than otherswhich are traditionally regarded as treatment Enriching the envir-onment of children (in the manner of ‘‘Headstart’’ programs) who canotherwise be expected to perform at a lower level than their wealthierpeers is surely more important than treating certain allergies, whenthe latter do not have a significant impact on the quality of life ofsufferers (which is not to say that we ought not to treat these allergies;

as well as asking how significant is the impairment, we also need toknow how extensive are our resources, in order to assess whether weought to treat them) In any case, and no matter how these moraldebates are settled, we must abandon the treatment/enhancementdistinction as an independent basis for moral judgment

a s s e s s i n g t h e c r i t i c i s m s

How ought we to respond to the criticisms of direct manipulations ofthe mind which apparently motivate the presumption against suchmanipulations? In the rest of the chapter, I shall consider theobjections one-by-one It might be helpful, however, to signal the

conclusion of this overview here I think that we ought to concedethat at least some of the points made by the critics are weighty, andthat we ought therefore to hesitate before we use direct manipula-tions We ought, that is, to assess each possible use to see whether itmight not be preferable to avoid it, for one or other of the reasonsoffered But, I shall argue, the larger claim that these reasons arewidely seen as supporting – that traditional means are always pre-ferable to direct manipulations, and that there is always a costassociated with the use of the latter – is false Though there arereasons to be cautious in the use of direct manipulations, I shallclaim, there is no reason to think that each and every use of suchmeans is somehow suspect Very often direct manipulations areperfectly permissible, and sometimes even preferable to traditionalmeans of changing minds; we can therefore use them, on ourselves or

on others, in good conscience In other words, we ought to drop thepresumption in favour of traditional means, and instead engage in thehard work of assessing each proposed use of direct manipulations onits own merits

Authenticity

Authenticity, as we defined it in the previous chapter, is the searchfor a way of life that is distinctively one’s own The authentic indi-vidual looks within, to find his or her own ‘‘measure’’ (Taylor1991)

It is this conception of authenticity that motivates worries like thoseexpressed by Elliott (1998); that the use of direct manipulations risksloss of contact between the individual and his or her authentic self.However, Elliott overlooks the fact that authenticity need not only

be inward-looking We can achieve authenticity by looking within,but we can also achieve it by self-creation We do not have to remaincontent with the kinds of people we are; we can seek to changeourselves, and we can do this within the horizon of the ideal ofauthenticity

The conception of authenticity emphasized by Taylor andElliott looks to the preexisting self to set standards In this

conception, we live authentically to the extent to which our lives areexpressions of who we, most deeply, really are But there are othernotions of authenticity, both in the philosophical literature andinfluencing everyday life well beyond the bounds of academic phi-losophy The notion of authenticity associated, above all, with Jean-Paul Sartre is importantly different, even opposed, to the notionpresupposed by Taylor and Elliott Authenticity for Sartre (1956)cannotconsist in expression of a pre-given self, for there is no pre-given self Sartre’s argument for this claim doesn’t bear up underexamination; nevertheless the claim itself is true What could con-stitute my essence, to which I am bound to conform? Some peoplecontinue to claim that personality is encoded in the genome, but as

we have just seen, in reviewing the way that genes actually interactwith the environment to produce phenotypes, that’s simply false Agene that contributes to the development of a personality trait – say,

a tendency to introspection – might have contributed instead to aquite different trait like extroversion in a different context Anexample: recently Terrie Moffitt and colleagues have investigated therelationship between genes and violence They found that men whopossessed a particular allele of one gene and who were maltreated aschildren were significantly more likely to exhibit violent behaviorthan men who possessed either the gene alone, or who had beenmaltreated but lacked the gene (Caspi et al.2002) It is clear that theallele is not a ‘‘gene for’’ violence, at least in the sense that having itdoes not predispose the person toward violence It is a gene for vio-lence given a particular environmental context

It might be replied that the fact that personality traits are notencoded in the genome is irrelevant Authenticity might be under-stood to mean, not harmony with a pre-given self – a self that isinnate in us when we are born – but with the self as it is, however itcomes to be Those mistreated adults who also possessed the relevantallele were not innately disposed to violence, but they were disposed

to violence The personality they came to possess was, authentically,theirs, and authenticity demands that they conform to it somehow

(not by expressing their violent disposition, one hopes, but byexpressing other aspects of their essential self, or by sublimatingtheir violence and channelling it into socially benign activities) Sodefenders of authenticity as harmony with a given self need notcommit themselves to biologically implausible views.

However, we cannot contain the interactionist point in thesuggested manner; we can’t limit it to childhood developmentwithout being entirely arbitrary Why should our personality at, say,eighteen be sacrosanct? In fact, people do continue to changethroughout their lives, sometimes subtly, sometimes quite drama-tically And very often we do not think there is anything wrong withsuch changes Consider the cases of Ruby and Elly Both seek treat-ment for longstanding, though minor, depression (I stipulate that thedepression is minor in order to avoid winning the argument cheaply:even critics of direct manipulation usually agree that we should use

it if it is the only way to avoid significant suffering) Ruby’s doctorprescribes an SSRI, and after several weeks of taking it Ruby feels hermood lift She is more outgoing and confident than ever before, andboth her professional and social life improve Friends and familyremark on the change in her Elly’s doctor, meanwhile, suggeststreating her depression without chemicals In fact, she suggests thatElly take up an exercise regime Elly begins jogging and going to thegym, and in a few weeks her mood begins to improve Six monthslater, she is doing as well as Ruby; once again the change in her isremarkable (on the effects of exercise on depression see Blumenthal

et al.1999; Salmon2001)

The first thing to notice is that very few people will be inclined

to accuse Elly of inauthenticity Sometimes it is appropriate to worrythat a friend is acting out of character We might be anxious for herwelfare because we think she’s far outside her comfort zone Wemight think that either she hasn’t really changed at all – she justpretending, perhaps well enough to fool herself – or that the change is

so shallow that it’s unlikely to be sustained We fear that the time isnear when the mask will fall; she will be revealed for who she really

is, and that when that happens she will suffer shame, humiliation, orworse But these fears are predicated on the belief or suspicion thatthe change is neither deep nor permanent If she has changed, then

we can’t accuse her of inauthenticity Since there is no inner essence

to which she is compelled, indeed able, to conform, there is no son at all to accuse someone who changes of inauthenticity (so long

rea-as they satisfy the Sartrean conditions on authenticity: roughly, theyrefuse to make any excuses for their choices, but instead takeresponsibility for them) Elly’s change might be entirely authentic;similarly, we are not generally inclined to accuse those who gothrough religious conversions or similar life-changing epiphanies –the man who leaves his desk job and his staid existence to performfamine relief in the third world; the woman who leaves her husbandand the suburbs to live in a lesbian relationship in a commune, orwhat have you – of inauthenticity, no matter how great the apparentchange in their lifestyle and personality

But if we should withhold the charge of inauthenticity so far asElly is concerned, then why should we treat Ruby any differently? Ofcourse, we might worry that Ruby’s transformation is less securethan Elly’s But there is no reason to assume that that’s the case.Indeed, it may be that it is more secure: taking a pill once daily issurely easier (side effects permitting) than adhering to an exerciseregime We may think that the difference in the means of transfor-mation equates to a moral difference: altering one’s neurochemistry

is interfering with the self in a way that qualifies as inauthentic,whereas exercise is not But that won’t stand up to examinationeither In fact, exercise is successful at relieving depression, at least

in part, because it functions (in much the same way as depressants) to increase the amount of serotonin available for trans-mitting signals across neural synapses

anti-Elliott, as we saw, argued that if Prozac gives us a new sonality, we become inauthentic: the new personality is not trulyours(1998: 182) But that’s simply false: it is ours It’s different to ourold personality, to be sure, but so what? Why should we be bound to

per-that old personality? What grounds do we have for telling Ruby per-thatthough she feels cheerful and successful, she’s not really? Cheerfuland successful is as cheerful and successful feels and does Elliott’scharge apparently rests on the romantic, and biologically implau-sible, idea that we have an innate personality (DeGrazia2000) Once

we realize that selves are continually recreated and transformed,throughout life, we shall lose the urge to accuse someone of inau-thenticity on the grounds of character change alone

As a matter of fact, at least some people who take depressants experience the transformation as authentic Peter Kramer(1993) reports many instances where patients identify with the selfthey experience while on antidepressants Thus, when he took themoff the medication they would sometimes return voicing an oddcomplaint: ‘‘I’m not myself.’’ Kramer notes how strange the claimsounds ‘‘But who had she been all those years if not herself?’’ (1993:19) Nevertheless, the patients’ claim is better grounded than Elliott’s.The true self is the self that actually exists; so long as the alteration issustained and sustainable, and goes deep enough – so long, that is, as

anti-we can genuinely attribute the new personality to them – then there is

no reason not to regard it as theirs authentically.1

Self-knowledge and personal growth

Giving someone serotonin is not offering them a reason to becheerful, nor is to helping them to understand what made themdepressed in the first place, but giving them a course of psychother-apy might enable them to come to understand themselves better.Compare two agents cured of their depression, one by psychotherapyand one by antidepressants The first will possess significantknowledge that the second will not: knowledge about himself (abouthis history and about the structure of his psyche), and about hisrelationship to the world (about the kinds of life events which caused

or contributed to causing his depression, and about their true nificance and the extent to which depression is a rational response tothem) The person cured by direct manipulation knows none of

sig-that: they know only that they feel better as a result of taking a drug.Since self-knowledge is surely a valuable good, we have reason toprefer traditional means of changing minds to non-traditional.

Unlike the charge of inauthenticity, I think this charge hassome bite We really do sometimes have reason to prefer traditionalmeans of changing minds to non-traditional, on the grounds thatthe former are more conducive to self-knowledge than the latter.However, this fact does nothing to justify a general presumption infavour of traditional means, for two reasons First, it will frequently

be the case that we have no reason to prefer traditional means tonon-traditional on the grounds of self-knowledge; second, and moresignificantly, we shall sometimes have reasons for precisely theoppositepreference, on these same grounds

People who seek treatment for depression and mental illnessmay lack self-knowledge, in the sense that they may not understandwhat, in their personal history, caused their problems But that’s farfrom always being true Sometimes, they understand the sources oftheir problems already; the PTSD sufferer is an obvious example.Consider the patient that Kramer calls Lucy Freedman (1998),arguing against the use of direct manipulations, believes that Lucy’sproblems stem from ‘‘false beliefs, [that] are grounded in somethinglike a mistake in reasoning’’ (1998: 143) Lucy falsely interprets herboyfriend’s changing the channel on the TV as a rejection of her;therapy, Freedman claims, should be aimed at helping her to see hererror But Freedman’s interpretation of the case is wrong, as Kramer’sdescription of Lucy makes clear Lucy is intelligent and globallyrational; she recalls her personal history clearly and she knows thather over-sensitivity to rejection is a product of this history She doesnot, as Freedman claims, need help to see that her response is irra-tional; she already knows it is irrational That’s what brings her totreatment in the first place

So Lucy does not enter therapy in order to acquire true beliefsabout the source of her problems She understands herself and herreactions perfectly well She wants help preventing a response of hers