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Doctor, please make me freer: Capabilities enhancement as a goal of medicine

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Abstract

Biomedical innovations are making possible the enhancement of human capabilities. There are two philosophical stances on the role that medicine should play in this respect. On the one hand, naturalism rejects every medical intervention that goes beyond preventing and treating disease. On the other hand, welfarism advocates enhancements that foster subjective well-being. We will show that both positions have considerable shortcomings. Consequently, we will introduce a third characterization in which therapies and enhancements can be reconciled with the legitimate objectives of medicine inasmuch as they improve the capabilities that enable the freedom to pursue personal well-being.

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Notes

  1. Complementarily, see Hofmann (2001b); Saborido (2020, Chap. 8).

  2. Needless to say, autonomy has been also a recurrent criticism against enhancement. Unfortunately, here we do not have space to meet those critics properly. In the case of being interested, we recommend the clarificatory article published by Heilinger and Crone (2014) about autonomy-based objections and autonomy-promoting arguments in the human enhancement debate. In the case of autonomy in relation to genetic enhancement, see also Rueda (forthcoming).

  3. We take inspiration from the philosophical interpretation of this famous fictional character carried out by Saborido (2020, chapt. 2).

  4. There are further authors who defend the relevance of the TED, see Daniels (2000); Schermer (2013a); Schwartz (2005); Sparrow (2010). More specifically, in Buchanan et al. (2000), Norman Daniels argued that the TED can be supported by reasons of distributive justice. According to him, the naturalistic emphasis on normal functioning marks what a just society must guarantee with its public resources on the basis of fair opportunities (in a Rawlsian sense). In the third section, we will defend a more open-ended conception of justice in relation to enhancement from the capability approach.

  5. Parens (1998) explains that this term was coined by James Lindemann Nelson in reference to Saul Kripke’s (1980) “schmidentity”.

  6. Doctor Welfare is a figure that we have invented to embody the welfarist position and counter the naturalistic model (reluctant to enhancement) previously exemplified by Doctor House, the famous fictional character.

  7. Another alternative conception of well-being, although less widespread, is the hedonistic one. This was harshly criticised by Nozick (1974, pp. 42–5), who demonstrated with his imagined experience machine that we do not really think that well-being is just pleasure. If this were the case, we would not hesitate to connect ourselves to a machine that would provide us any type of pleasure that we wished. We want to enjoy ourselves if we have a reason for it (not just a cause for it) or, in other words, a reason that something has happened in the world outside our minds. Only this way we will say that our well-being has really increased—it is not just about feeling better. For a deeper understanding of the keys and limitations of this criticism see, for example, Bramble (2016), Glover (1984, Chap. 7–8) and Unger (1990, Chap. 9). Another less elaborate argument for questioning the identification of pleasure and true well-being could be constructed from the excessive use of pleasure-providing substances. In this line, studies have shown how deep brain stimulation of certain areas associated with pleasure can lead to compulsive self-stimulation and total indifference towards anything else (Portenoy et al. 1986).

  8. At this point, a clarification is necessary. Although Nussbaum (2007, pp. 179–195) focused on “the species norm”, she does not rely on a strict naturalistic view of species-typical functioning related to the philosophy of medicine. Rather, she used it to refer to an Aristotelian conception of dignity, in the sense that a minimum threshold of central capabilities is needed to have a dignified human life. We align more with the Senian approach that does not endorse particularly with this view of dignity and who stress primarily the role of public reasoning and what people have reason to value in deciding the most important capabilities (Sen 2004).

  9. According to hierarchical conceptions of procedural autonomy, self-reflected high-order desires are more authentic and of greater importance than first-order desires (Dworkin 1988; Frankfurt 1971).

  10. Procedural autonomy is one of the plausible interpretations that could be given to ‘having reason to value’. According to Khader and Khosko (2019), that interpretation is consistent with Sen’s refusal of establishing a fixed list of valued functionings, but it is inconsistent with the possible general disvalue of the content (even if reflectively arrived) of some particular functionings. The commitment of procedural autonomy with content-neutrality and its avoidance of comprehensive substantive values (Christman 2005) could conflict, therefore, with the fact that some functionings may generally be considered of negative valence. Khader (2009) also challenged the predominant view of adaptive preferences as deficits in procedural autonomy.

  11. A debate that we do not have space to address here is whether some kind of emotional enhancement would also be beneficial for procedural autonomy enhancement. In other publications about moral enhancement, we have argued that empathy enhancement may result in an epistemic advantage that could lead to a more autonomous decision-making (Lara 2017; and Rueda and Lara, 2020). For procedural moral enhancement, see also Schaefer and Savulescu (2019). Moreover, we do not rule out that emotional and cognitive enhancement might sometimes overlap. We also have no space to address here the relevance of the social context and of the emotional and embodied aspects of autonomous decision-making that have been highlighted from relational accounts of autonomy. The concept of relational autonomy is useful to solve some alleged shortfalls of the procedural perspectives such as not taking into account: (a) the role of emotions and how they affect the agent’s competence by relying on fully rational and dispassionate reflection, and (b) that the person builds her practical identity in relationship with a particular social environment. On the other hand, these appeals to the influence of the social environment run the risk of becoming substantive proposals for autonomy that could lead to a perfectionist and paternalist regulation of society (Friedman 2003; Mackenzie 2008; Mackenzie and Stoljar 2000; Stoljar 2017).

  12. Cognitive enhancement can be achieved also by a wide variety of conventional and mundane methods, such as education, enriched rearing environments, diet, caffeine, long-term exercise, mental training, or prenatal supplementation (Bostrom and Sandberg 2009).

  13. Might be worth citing that, according to an online informal survey conducted in Nature, around one in five of academics and health professionals make use of cognitive enhancement (Maher 2008).

  14. In addition to genetic cognitive enhancement, one of us defends that targeting the genetic basis of addictive behaviour is another option to improve future children’s capabilities for procedural autonomy (Rueda, forthcoming).

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Funding

This article is part of the research project EthAI+ (Digital Ethics. Moral Enhancement through an Interactive Use of Artificial Intelligence), funded by the State Research Agency of the Spanish Government (PID2019-104943RB-I00). Jon Rueda also thanks the funding of an INPhINIT Retaining Fellowship of the La Caixa Foundation (Grant Number LCF/BQ/DR20/11790005). Pablo García-Barranquero also thanks the funding of Contrato Puente para Doctores (2019–2020) and Contrato Postdoctoral (2021–2023) of the University of Málaga.

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  1. Department of Philosophy 1, University of Granada, Granada, Spain

    Jon Rueda & Francisco Lara

  2. Department of Philosophy, University of Málaga, Málaga, Spain

    Pablo García-Barranquero

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  1. Jon Rueda
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Rueda, J., García-Barranquero, P. & Lara, F. Doctor, please make me freer: Capabilities enhancement as a goal of medicine. Med Health Care and Philos 24, 409–419 (2021). https://doi.org/10.1007/s11019-021-10016-5

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