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September 27, 2007

Before reading The Case Against Perfection David Wootton thought he agreed with Michael J. Sandel on genetic selection and genetic therapy - now he sees how weak Sandel's arguments are: The Case Against Perfection - Michael J. Sandel

Posted by David Wootton

The Case Against Perfection: Ethics in the Age of Genetic Engineering
by Michael J. Sandel
Cambridge, Mass: Belknap Press, 2007
Hardback, £12.95

We are stumbling into a future so unlike the present we can hardly imagine it. One day quite soon it will be possible not just to screen foetuses for conditions such as Down's syndrome, but also to modify them to improve their hand-eye co-ordination, musical ability, or mathematical prowess. And it will be possible to swallow a pill which will not just treat Alzheimer's or muscular dystrophy, but which will, by adjusting your genes, improve your memory before an exam, or improve your muscle tone before a marathon. Which of these possibilities are to be desired, and which ought to be forbidden?

Michael J. Sandel's book is designed to provoke serious thought about this question. He gives some striking examples. In the US, for example, it is legal, under the terms of a trial approved by the Food and Drug Administration, to select the sex of your child not only to reduce the transmission of diseases inherited in the male line, but also for "family balancing".

A trademarked process called MicroSort, developed for use in cattle breeding, enables parents who have more children of one sex than the other to select the sex of their next child: the cost seems moderate (around $4,500), until one notices that one has to multiply by more than three to get a 50% chance of a conception, and even then there is a 10% chance of ending up with a boy when you have been trying for a girl, and a 25% chance of ending up with a girl when you have been trying for a boy.

In the UK the Human Fertilisation and Embryology Authority thinks a child might be psychologically damaged by the knowledge that it had been selected for its sex, and opposes selection for family balancing. Sandel cheerfully tells us that more parents want girls than boys, but neglects to tell us that this is probably not because girls are thought to be nicer, but because some boys carry genetic defects.

Sandel's conclusions will be attractive to most secular liberals. He is in favour of screening foetuses for Down's syndrome, but against designing foetuses that will win Nobel prizes. He is in favour of gene therapy to treat diseases, but against gene therapy to make us better golfers or musicians. He is in favour of research on stem cells, which should make gene therapy possible, and rejects the claim that this involves the taking of innocent lives, arguing that a blastocyst (from which stem cells are derived) is not a foetus (its cells are not differentiated), let alone a person. He is far closer to the consensus view in the UK than in the US.

Above all, Sandel wants us to accept the unpredictability of our natural inheritance: to see life as a gift, which we must respect and nurture, not as a raw material which we are entitled to refashion to suit our purposes. In employing this language of "gift" and "respect" Sandel acknowledges that conventional secular ethical language seems inadequate when discussing the issue of gene therapy.

Sandel's arguments assume that governments can successfully regulate the availability of gene therapy - which is broadly true at the moment, but may not be in the future. After all, the sale of Viagra is regulated in theory, but not in practice. Is it really possible for us to acquire a technology, and then collectively agree to restrict its use, even though it will do things many of us want to do, and will impose no immediate harm on others? It would be helpful to have some case studies of such forms of self-restraint.

This faith in government regulation is particularly striking because it is at odds with another of Sandel's assumptions. He takes for granted a free market world in which people can legitimately buy a better education or better health care for their children, so he has to acknowledge that it is not immediately obvious why they might not be entitled to buy them a better physical endowment - which is why he has to look for some unobvious reason.

He also makes a larger and less obvious assumption: he assumes that gene therapy is a high-technology process. A recent article in the Journal of Neuroscience (Feb. 14) however claims to show that when mother rats lick their infants they alter their genetic characteristics. Anxious mother rats, who have little time for licking, produce rats genetically predisposed to anxiety; secure mother rats, who lick frequently, produce secure offspring - and these predispositions are then inherited as a default condition by the next generation.

If this is right, mammalian mothers practice gene therapy all the time. If gene therapy is part of normal social interaction, does this make it easier to argue that it present no new ethical problems, merely old problems in somewhat new guises? (Similar results have been reported for chickens – see The Economist, 21st April, p. 105 – although mother chickens cannot modify their offspring’s genetic predisposition after hatching.)

So much for the assumptions. There are four arguments Sandel relies on. First, he thinks we can distinguish between treating a medical condition and enhancing our abilities. But can we? In the US human growth hormone has been approved for the treatment of children with a hormone deficiency; but many parents are prepared to pay to have normal children treated so that they will grow up taller; and the FDA now officially approves treatment for those whose adult height is projected to fall in the bottom one per cent. Now it is clear here that the line the FDA has drawn is an arbitrary one. Why not the bottom five per cent? Or the bottom ten per cent?

We standardly think deafness and blindness are medical conditions that ought to be corrected if possible - many were horrified when a deaf couple who could not reproduce in the traditional way (they were lesbians) sought out a sperm donor with five generations of deafness in his family in order to have a deaf child. But don't we all want our children to speak the same language as we do, and to share their lives with us? Those of us who are not deaf might well feel we could legitimately screen for deafness in the foetus, and would surely feel we can legitimately treat deafness in the child. The question of whether it would be appropriate to screen for deafness is of course contentious: Joanna Jepson has fought against the notion that it is appropriate to screen for cleft palate, a condition she has herself; but it does not follow from the fact that one is glad to be alive oneself that screening is necessarily wrong.

But if one can screen for cleft palate or deafness, what then of colour blindness, dyslexia, or inability to sing in tune? It's clear that the distinction on which Sandel relies, between therapy and enhancement, between conditions where intervention is legitimate ("disabilities" let us call them: the fact that the term is highly contested will help us keep in mind the scope for disagreement over what is and what isn't a disability) and those where intervention is illegitimate ("inaptitudes", let us call them), is going to be arbitrary.

Many of us already have or are going to end up with replacement hips. Presumably gene therapy that made surgery unnecessary would be legitimate in Sandel's eyes. But he would think it illegitimate to give a footballer gene therapy to strengthen his anterior cruciate ligament so that it would not tear; and this despite the fact that it is obviously legitimate to operate on the ligament after it has torn. Gene therapy for Alzheimer's: legitimate. Gene therapy for routine memory loss in old age: illegitimate. Gene therapy for exceptional memory loss in old age: let's ask the FDA to rule. Gene therapy for impotence: legitimate. Gene therapy to enhance sexual performance: illegitimate. Gene therapy for physical deformity: legitimate. Gene therapy for wrinkles: illegitimate. And what if your wrinkles make you feel deformed?

The fact that distinctions such as these involve drawing lines in rather arbitrary places is not necessarily a decisive argument against them. As Sandel says (p. 49),

Like all distinctions, the line between therapy and enhancement blurs at the edges.
We would all find it hard to explain why one crime should be punished by community service, while another, only slightly worse, should be punished by time in prison. Still, if we have to make these distinctions, we must also be prepared to give reasons for them. And the distinction between a disability and an inaptitude is clearly as much cultural as it is scientific, and is going to be subject to renegotiation over time.

On Sandel's way of thinking, it is ok to treat conditions if they are recognized medical conditions; but of course anything can be recognized as a medical condition if we and the doctors want it to be. Kleptomania, alcoholism, homosexuality: some think these are medical conditions, others don't. Might it not be better to start by acknowledging that to say that intervention is legitimate when one is dealing with recognized medical conditions is simply to argue in a circle? There is nothing circular, by contrast, about arguing that crimes of violence should be punished by incarceration and that crimes of deception should not.

Second Sandel thinks that selecting a child so that it has a particular genetic endowment is morally wrong. Why? Because it is an act of hubris on the part of the parents. It is worth remembering though that parents already select the genetic endowment of their children indirectly when they choose a partner. Musicians mate with musicians, and quite reasonably expect their children to turn out musical.

Still, Sandel thinks we ought to accept that we are not meant to choose our children, and our children ought to be able to think of their genetic endowment as a "gift" not a choice. The language of gift, Sandel claims, can be sustained even if we do not believe in a giver - God or Nature. It is true that we talk about a gifted musician without intending to imply that God is responsible; but the language of "gift" here is simply a euphemism for a language which ranks abilities: a gifted musician is one who isn't second-rate, or worse, third-rate.

It's easy to use the language of giftedness if you are excellent at something. But what if you are just plain average? What sort of gift is that? The language of gift either implies a supernatural reference point (which Sandel wishes to avoid), or it implies that most people are not gifted but relatively disadvantaged (an implication that Sandel must seek to avoid, as we might well want to intervene to overcome disadvantage). I can see how Sandel might hope to avoid one of these implications; but it seems to me he can only do so at the price of accepting the other.

Third, Sandel thinks choice creates obligation. If my parents have chosen that I am to be clever, then I am going to be under an obligation to do well at school; while if I am just born clever it is (supposedly) up to me what we do with my gift. Here Sandel clearly sees there is something problematic about his argument. Supposing I spend £250,000 buying my child a first-rate private education. Does that put the child under an obligation to succeed? If it does, then it is clear we can't escape from the problem by banning designer babies. If it doesn't, then it is not clear why my buying my child good genes should create an obligation where my buying them a good education doesn't.

Sandel tries to wriggle out of this by saying parents shouldn't push their children too much, and by claiming that what his argument exposes is the moral difficulty associated with parents planning for their children to succeed - he calls this "hyperparenting". Fine. But we don't ban maths coaching or ballet classes because some parents don't realise their children will have lives of their own. So why should we ban genetic selection? A number of secular liberals, such as Ronald Dworkin, have apparently concluded that it is morally wrong not to select (for good health, for example), provided the selection is made freely by parents, and not by the state. I can't see that Sandel's argument against selection is clearly better than theirs in favour.

Fourth, Sandel relies on the sorites paradox to distinguish between a blastocyst and a person. How many grains of wheat does it take to make a heap? Five grains are not a heap, but perhaps thirty are. It is often wrong to cut down an oak tree, but acorns can always be fed to pigs. At some point in its development, we (if we are secular liberals) recognize that a foetus has rights, but the point is an arbitrary one, just as the moment when we say we have a heap of grain is arbitrary.

The problem here is that adding grains to make a heap doesn't alter our moral relationship to the grain: it still belongs to somebody, it is still food, whether we are talking about a teaspoon of grain or a bushel. And the same is true of the acorn and the oak - there's nothing morally wrong with cutting the oak down and turning it into furniture, though we do need to take into account the difficulty of replacing it. When a blastocyst turns into a person, however, a new set of moral obligations come into existence. The sorites paradox doesn't help us think about this transformation.

Sandel wants to find a path between utilitarianism and divine law. There are all sorts of difficulties associated with trying to find such a path, though most moral philosophers are committed to looking for it. But the issues are muddied, not clarified, if we say we must "respect" oak trees, blastocysts, and works of art, particularly if we imply that the word "respect" is doing the same work in each case. It seems to me a utilitarian can give a perfectly good account of why harvesting grain and harvesting oaks are very different activities, and can do so without using words like "respect" - they may, on the other hand, have a good deal of difficulty in explaining what is valuable about a work of art without reducing it to cash value or source of pleasure. But I'm not sure the word "respect" helps there either. The question of whether I should respect a Duchamp urinal, for example, is far from straightforward.

Sandel wants us to have an attitude of respect towards blastocysts, while insisting they are not people, and so can be used for experimental purposes. But if a human blastocyst is not a person, then is there any reason why it should be shown more respect than a dog blastocyst, or a fertilised fruitfly egg? And surely a fruitfly egg is entitled to no more respect than we would show towards a fruitfly? So perhaps human blastocysts aren't entitled to much respect after all.

If we ask how much respect we should show an oak tree, a human blastocyst, or a Van Gogh painting the right answer is going to be that it all depends on the circumstances. If this blastocyst is your only hope of having a child by your deceased husband then it is a potential life and of enormous value, at least to you; if you have hundreds of others in the freezer then it is a spare part. If there's a Van Gogh in a burning building I should try to rescue it - but only after all the human beings have been rescued. If there is a fridge full of blastocysts in a burning building I'm under no obligation to rescue them if all the donors are still living and capable of producing eggs or sperm. Whether the same argument applies to a Duchamp urinal depends on whether you think it is a unique (or at least rare) object, or a mass produced one.

What this book has taught me is that I don't know what I think about genetic selection and genetic therapy. This is quite an achievement. Before I read Sandel, I agreed with him. But now I see how weak his arguments are, I think there really is a strong case for using genetic therapy to correct inaptitudes as well as disabilities (for what Sandel calls "enhancement"), and for using genetic selection to produce healthy and intelligent children.

In any case, whether we like it or not, it's going to happen. Couples seeking artificial insemination, in the US at least, can deliberately seek donors who are clever, fit, or deaf. It can only be a matter of time before women can screen their own fertilised eggs for these attributes, or modify them to enhance them - and when they can, they will. It's deeply ironic that Sandel begins his book with a consideration of performance enhancing drugs in sports - he thinks the arguments that justify banning steroids also justify banning genetically enhanced sportspeople. And yet, as he also admits, all American professional sports are dependent on performance enhancing drugs. Do we really want to embark on a war on gene enhancement if it is going to be as futile as the various wars on drugs?

What this book has also taught me is that one really needs a comparative perspective with which to think about these things. In the US and the UK clinics implanting fertilised eggs are allowed to produce surplus eggs - it is these surplus eggs that can be used for research in the UK, but not for government-funded research in the US. I listened to a report on Woman's Hour on Radio Four (21st February 2007) on the ethical issues raised by women donating eggs for research purposes: the report didn't even bother to mention that the eggs were of course going to be fertilised, and were then going to be killed; it was concerned only with the health of the women donors.

In the US, by contrast, the federal government thinks the cloning of stem cells from embryonic tissue involves killing a human being; but it permits research on existing cell lines, although they too come from cloning, and it permits the destruction of unused blastocysts, although this too (in the context of the government's arguments) must be the killing of a human being. In Germany, the production of surplus eggs is banned, so the issue doesn't arise.

In the UK the reproductive cloning of a human being is illegal; in the US it isn't because they can't agree on the definition of a human being (too many legislators also want to ban the cloning of stem cells). In the US genetically modified crops can be grown legally, and there is no obligation to identify them at the point of sale; not so in the UK. It is all too easy to assume that the particular compromises established in one's own country are defensible or sensible - until one realises that other countries have come to quite different conclusions. Just as women used to travel from Eire to the UK for abortions, so soon they will be travelling from the US to the UK for genetic therapy, and from the UK to China, perhaps, or South Korea, for the genetic selection and manipulation of embryos.

For centuries we have bred crops and animals to fit our requirements. Soon it will be possible for us to breed ourselves to suit our purposes, and to do so with even greater success. The prospect seems utterly repugnant. And, if we could choose, what would we choose? Screening for cancer may one day make the same sense as screening for porphyria. But would any sensible person want their child to be Mozart, or Edith Piaf, or Elvis Presley? A friend of mine, with such examples in mind, used always to say he wanted his child to grow up to be a plumber. Unfortunately (or perhaps fortunately), he grew up to be a nuclear physicist.

It is an important fact of life that our children do not become the people we imagined they would. My father was a clergyman: if he could have, he would have ensured I was genetically endowed for piety and credulity. I'm delighted my parents didn't get what they wanted, so I'd be the last to vote for a world in which parents have more power over their children than they do already. The problem isn't that choice is morally wrong. It isn't that choice is often self-defeating (though of course if we all opt for taller children, half our children will still be below average). But it certainly is a problem that some parents will make very bad choices for their children, just as they do now.

It is one of the great problems of life that adults have power over children, and most adults are unfit to exercise that power. It is one of the great advantages of contemporary society over almost all previous societies that the power of parents over their children - their power not only to physically abuse them, but also to choose their occupations and to select their spouses - has diminished. Would genetic selection and gene therapy make children more vulnerable to adult power, or less?

The answer to that question must depend in part on how adults would exercise their power of selection. Would we end up with a society where everyone was selected to be like everyone else; or one in which difference, originality, initiative were highly prized? Would we end up with Tocqueville's tyrannical majority, or John Stuart Mill's ideal of liberty through self-expression? Would we select so that our children would be rich and famous? Or so that they would be happy?

If what Sandel calls "the new eugenics" (to distinguish it from the old eugenics of state selection), by which he means parental selection, is inevitable, as I believe it is, then the burden of responsibility that parents bear is going to become greater, not less. This is not an attractive prospect, but how easy will it be to choose, as Sandel thinks we should, to adopt an irresponsible attitude to our children's wellbeing?

David Wootton is Anniversary Professor of History, University of York. He is the author of Bad Medicine: Doctors Doing Harm Since Hippocrates.

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