‘It’s Not Fair!’

Is rectifying a physical or mental deficiency the same as giving someone an ‘unfair’ leg up in life? Medical student Frances Butcher considers both sides.

‘Fair’ is not a word widely used by healthcare professionals – it’s not fair if a young mother is diagnosed with breast cancer – but voicing this may not help. A similar reason is used when a small child complains of unfairness – perhaps a friend beat them at a race because they just aren’t that fast.

Traits like athletic ability or IQ can be ‘naturally unfair’ due to human genetic variation. This unfairness can even be applied to fundamental characteristics such as our gender and ability to reproduce. But what if biomedical techniques could alter this? While enhancing yourself to an Einstein-ian level IQ might raise cries of unfairness to the rest of society – does the same argument apply to raising a below average IQ to the mean level?

Principle

One way to define biomedical enhancement is as medical interventions that have the potential to augment human capacities. Although a widely discussed topic in medical ethics, much of the debate has focused on the individual enhancing themselves to ‘superhuman levels’ and the negative effects on society if individuals are allowed to do so. Fewer have attempted to claim a positive social potential or a more ‘mediocre’ individual benefit.

Dr Tom Douglas, a Wellcome Trust Ethics and Society Fellow, has argued that a form of ‘fair enhancement’ could, theoretically, be desirable to society. This ‘fair enhancement’ could allow individuals to mitigate their allegedly unfair characteristics, such as boosting a below average IQ to an average level.

You could argue that this is no different to a trauma victim – someone who hurt themselves falling off a ladder, say. What’s the difference between an individual with an IQ of 100 and someone who’s IQ drops from 150 after a head trauma, which reduces his IQ to 100. Both would benefit if a medical technique were available to raise IQ (improving their job prospects, economic status etc.), yet one could be a medical treatment and the other a medical enhancement. Is it ‘unfair’ to treat these individuals differently when the intervention has essentially the same indications and expected prognosis?

A similar problem is seen in many areas in medicine. A recent breakthrough by scientists in Japan demonstrated that stem-cell derived sperm could be used to produce healthy and fertile offspring in mice. Producing a new infertility ‘treatment’ for men is the first potential application of this technology. Other applications might be to produce eggs for post-menopausal women – but also eggs for men.

Although not a typical enhancement, this use could also be considered an augmentation of human capacities.  Dr Anna Smajdor’s Wellcome Trust-sponsored PhD looked the ethical and sociological issues arising from artificial gametes. She argues that the reality of these artificial gametes would make the provision of infertility treatment on the basis of clinical need “conceptually unsatisfactory”. Almost anyone could be considered to have a ‘clinical need’ for this assisted reproduction technology. For it to be fair, would it be necessary to provide this to everyone who requests it?

It might seem obvious that there are differences between the potential applications. Enabling an infertile man to conceive with his female partner enables a natural characteristic: men produce sperm. Enabling two gay men to produce sperm and eggs is unnatural: men do not produce eggs. While this is perhaps an instinctive argument, it’s discriminatory to equate morality with nature. And in philosophical terms, this rarely stands scrutiny – medicine is itself an unnatural intervention. Consider also that in about 23 per cent of male-female cases, the cause of infertility cannot be identified, and these couples could be considered ‘naturally infertile’ too.

Bar the development of artificial wombs, prospective gay parents still need a surrogate, but society already accepts this, to an extent, through celebrity cases like Elton John. As artificial gametes cannot be provided on the basis of clinical need, Smadjor argues that an all or nothing approach to accessing this technology should be used.  To apply restrictions – for example to access for gay men – would be making a social or moral judgement about who could be good parents.

Practice

Many questions in medicine fall at the stumbling block of allocating resources. Should a fair ‘enhancement’ have to be available to everyone to attempt to improve social fairness?  Or would individual fairness be sufficient?

The ideal scope of medicine would include some of these fair enhancements – certainly the World Health Organisation’s definition of health as “a state of complete physical, mental, and social well-being” could). But we know that in reality medicine cannot take such a broad approach.

The range and priority of enhancements is also a matter of importance. Is raising an IQ more important than creating an artificial egg for a man? Cognitive enhancement is extremely problematic as it is a continuous variable – we can enable fertility but we improve IQ.  Defining a fair IQ creates the problem of a slippery slope and potential arms race.

Even if supply of these types of fair enhancements was on a private – or even a public lottery –process, these might lead to increase in fairness for the individual receiving them. It is questionable whether a fair enhancement only available to some would increase, decrease or retain neutrality on social fairness.  And this is where the development of some of these technologies may pose a ‘dual use dilemma’. Douglas, who is currently researching this, argues that, in practice, many of these enhancements are likely to be used more for harm than good – improving the lot of the ‘haves’ and widening the gap to the ‘have nots’. And  Smadjor warns about the assumption that therapeutic uses of medical technology are somehow ideologically ‘pure’, whereas non-medical uses aren’t.

A reality check. These techniques won’t be available anytime soon. But despite this, the debate around them is gradually is reaching greater public prominence. This is probably a good thing – as well being a fascinating subject, the potential applications need to be considered by a wide as audience as possible. Although these developments have the exciting potential to reduce some of life’s unfairness, perhaps the awkward combination of medicine, enhancement and the social good isn’t quite there (yet).

Frances Butcher

References

Bostrom, N, Roache R.  Ethical issues in human enhancement.  In: Ryberg J, Petersen TS, Wolf C (eds).  New waves in applied ethics.  Hampshire: Palgrave Macmillan; 2008.

Katsuhiko Hayashi, Hiroshi Ohta, Kazuki Kurimoto, Shinya Aramaki, Mitinori Saitou. Reconstitution of the Mouse Germ Cell Specification Pathway in Culture by Pluripotent Stem Cells.  Cell – 04 August 2011