Therapy and Enhancement meeting 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 (unpublished)

n The framing of discussions of gene technology (GT) in bioethics F 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! F 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). n I’m a sceptic on both counts => new framing in terms of the ethics of risks

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

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