ethics 6

x Introduction

fairly particular conceptions of a good life. Margaret Olivia Little investi- gates how cosmetic surgery can make purchasers and practitioners become complicit with what she calls "suspect" conceptions of normality, while from a vastly different perspective and in a very different mode, Susan Bordo articulates the same concern in "Braveheart, Babe, and the Body: Contemporary Images of the Body." Bordo presented an early version of that essay at our second project meeting; she then published it her book, Twilight Zone: The Hidden Lfe of CuItural Images from Plato to 0.1. (Berkeley: University of California Press, 1997). We reprint that essay here with permission of the author and the University of California Press.

The volume's final papers broach the daunting question, What sort of people do we want to become? Gerald McKenny reviews some of the dominant Western philosophical conceptions of how medicine should use technology to respond to the vulnerability of human bodies. In so doing he shows the often underappreciated ethlcal significance of those responses. Like McKenny, Mary Wlnkler also undertakes her explora- tion in a rich historical context. Whlle Winkler has concerns (as does McKenny) about using biotechnologies to enhance our capacities and

traits, she does not argue for the blanket of any pven enhancement purpose. Rather, like the project as a whole, she tries to articulate as clearly as possible what is ethically at stake when we use new biote~hnolo~ies to achieve such purposes. She helps us ask the right questions.

If it weren't for LeRoy Walters's talk on enhancement in 1993 at The Hastings Center, the energy necessary to drive thinking about a project might not have been generated. If it weren't for Daniel Callahan's guidance and nudging, the grant application to the NEH would not have been finished. And if it weren't for the careful administrative work of Nicole Rozanski, this volume would not have made it to John Samples's office at the Georgetown University Press. I am indebted to those individuals, to the contributors to this volume, and to the following individuals who also made presentations and/or attended project meet- ings: W. French Anderson, Adrienne Asch, Erika Blacksher, Bette Crigger, Eve DeVaro, Lawrence Diller, Strachan Donnelley, Harold Edgar, Mark Hanson, Bruce Jennings, Peter Kramer, Sheldon Krimsky, Tracy Macdonald, Glen McGee, Ellen Moskowitz, Leigh Turner, Law- rence Vogel, LeRoy Walters, and Peter Whitehouse.

Is Better Always Good?

The Enhancement Project

Worry about enhancement? Why not worry instead about apple pie? Enhancement, after all, is somedung we seek for ourselves and think others should too. We praise individuals who exercise so that they will live longer, be thinner, and if not richer, at least happier. We applaud individuals who seek excellent schools to enhance their intellectual development. We praise parents who do everythmg they can to enhance their children's moral development. So why would anyone worry about , a new cosmetic surgery technique that promised to make us thinner? Why worry about a new psychopharmacological agent that promised to enhance concentration and performance in school? What about a new psychopharmacological or genetic technology that promised to make us kinder and gentler?'

The following essay begins to say why and when it will sometimes make sense to worry about the prospect of aiming new biotechnologies at the enhancement of human capacities and traits. When we began our two-year project funded by the National Endowment for the Hu- manit ie~,~ we hoped to articulate for policymakers what we called "a continuum of uses of 'enhancement technologies,' from those that promote shared values, to those that seem neither to promote nor threaten shared values, to those that threaten such values." That hope was misguided in a couple of ways. First, it failed to appreciate that the heterogeneity of the technologies and the number of problems surrounding their regulation make the idea of "a continuum" unrealistic. Second, the phrase "enhancement technologies" itself is potentially mis- leading. The phrase could be read to suggest that "enhancement techno- logies" are in a class different from, say, the class of "health technologies." But of course they are not. The same technology can be aimed a t

different purposes. A genetic technology that could increase muscle

2 Erik Parens

mass for the purpose of treating a patient with a degenerative muscle disease could also be used to enhance the ability of an athlete to compete at lifting weights.

In a word, we quickly discovered that our project's primary aim should be to help clear some of the conceptual ground. This purpose entailed not only trying to clarify the different ways in which the term enhancement is used, but trying to clarify some good reasons why anyone might worry about aiming new biotechnologies at the enhancement of human capacities and traits.

One of the things we learned is that to understand womes about enhancement, one needs to notice that the term enhancement is used in at least two different, albeit sometimes overlapping, sorts of conversa- tions-and for dfferent reasons. In the first sort of conversation, en- hancement is one pole of the treatment/enhancement distinction. It is used in conversations by people attempting to say what doctors, as doctors, should and shouldn't do or by people attempting to say what a just system of health insurance should and shouldn't provide. Ths conversation is often conducted, explicitly or implicitly, in terms of the proper goals of medicine.

In the second sort of conversation the concern is not primarily that doctors might provide an intervention that would undermine the proper goals of the profession. Rather, the concern is that anyone who provided the intervention would be undermining extramedical, social goals or would be exacerbating already existing social problems. The first half of this essay is devoted to enhancement as it appears in conversations about the goals of medicine; the second half is devoted to enhancement as it appears in conversations about what might be called the goals of society.

In the essay that follows I draw heavily on the work of the project participants, but do not claim that all would share my conclusions. In particular, some participants think the term enhancement is so freighted with erroneous assumptions and so ripe for abuse that we ought not even to use it. My sense is that if we didn't use enhancement, we would end up with another term with similar problems. Rather than attempt to come up with a term that is free of such problems, it is my view that we ought to begin with what we've got, and try to articulate as clearly as possible what the dangerous and problematic uses are. I elaborate such uses below, but invite the reader to consult the essays that follow. Indeed nearly every aspect of my overview is elaborated in at least one of these essays.

Is Better Always Good? The Enhancement Project 3

Enhancement and the Goals of Medicine

As mentioned above, the treatment/enhancement distinction is often used in the context of conversations about what falls within and what falls outside the proper goals of medicine. But as anyone who has participated in or observed such a conversation knows, there is no one universally accepted conception of the goals of medcine. The lack of such a consensus has much to do with the fact that there is no one universally accepted conception of what health is. And thus neither is there a universally accepted definition of what "going beyond health to enhancement" means.

Within the goals of medicine conversation, there is, in the starkest terms, a long-standing debate between those who view health as freedom from disease and those who, like the authors of the famous World Health Organization definition, view health as "a state of complete physical, mental, and social well-being." In Norman Daniels and James Sabin's terms, there is a long-standing debate between "hard-line" and "expansive" conceptions of health, and thus between "hard-line" and "expansive" conceptions of the goals of medicine in particular and of health care more generally.

The Treatment/Enhancement Distinction and the Normal Function Model Perhaps the most persuasive defender of the "hard-linen-or "normal

function'-view is Norman Daniels. On this view, "disease and disability are seen as departures from species-typical normal functional organiza- tion or fun~t ion in~ ."~ As Daniels puts it, "According to the normal function model, the central purpose of health care is to maintain, restore, or compensate for the restricted opportunity and loss of function caused by disease and disability. Successful health care restores people to the range of opportunities they would have had without the pathological condition or prevents further deterioration."' One of the roots of this view is the conviction that the primary aim of health care is to provide people with normal function so that they can have an "equal opportunityn to pursue their life plans.

The terms "normal" and "equal" can be a bit confusing here. At the heart of the normal function model is the view that health care ought to help people become "normaln-which is not to say uequal"-competi- tors. Crudely put, the normal function model accepts that people are unequally endowed with respect to traits and talents; it accepts that

4 Erik Parens

"by nature" individuals are not equal competitors. The normal function model insists, rather, that those unequal competitors are entitled to an equal opportunity to pursue their life plans within the limits set by those natural endowments. On this view, medicine's primary goal is to restore people to the normal function that disease and disability diminish and whlch is the necessary condtion for them to pursue their life plans.

Proceeding from such a conception of health, disease, and the goals of medicine (and health care), Daniels writes: "Characterizing medical need [as what has to be done to restore species-typical functioning] implies a contrast between medcal services that treat disease (or disabil- ity) conditions and uses that merely enhance human performance or appearancen6 (emphasis added).

There are at least two uses of the distinction between interventions that aim at treatment and interventions that aim at enhancement, be- tween interventions that aim at the restoration of species-typical function and enhancements that aim at something more. The primary use, and the one that motivates Daniels, is as a tool to articulate what just health care entails. On his account, a just and basic package of care would include treatments but exclude enhancements. A just system of national health care insurance, for example, would cover the former but not the latter.

The second use is as a tool in the fight against medicalization. That is, the normal function model helps to identify the proper domain of medicine s u c h that some forms of disease are beyond its proper reach. Daniels and Sabin introduce an example of what I mean in their essay, "Determining 'Medical Necessity' in Mental Health Practice."' They point out that many different kinds of shyness can produce dis-ease in this society. The normal function conception enables us to distinguish among such kinds: to distinguish, for example, between shyness that is caused by "illness" and hence deserves treatment, and shyness that is caused by "life" and which, while worthy of response, does not deserve the services of a health care system with limited resources. As Daniels and Sabin point out, in contrast to expansive models of the goals of medicine, the normal function model enables us to make a "moral distinction between [the] treatment of illness and [the] enhancement of disadvantageous personal capabilitiesn (p. 10).

According to the normal function model, "complete physical, men- tal, and social well-being" is beyond the proper domain of medicine. The ability to identify what is beyond medicine's proper domain is

Is Better Always Good? The Enhancement Project 5

enormously appealing to people who worry that too much is being brought within it. Insofar as the normal function model accepts that people are thrown into the world with different endowments, it can be a tool to fight medicalization; it can help us to remember that there are natural differences and characteristics that medicine ought not to be used to erase.

Problems with the Treatment/Enhancernent Distinction As do all distinctions and models, however, this versions of the

treatment/enhancement distinction and the normal function model has several problems-having to do with the intelligibility of the distinction and with the assumptions embedded in it, as well as with the uses to which it might be put by unreflective policymakers.

One of the first problems with Daniels's version of the treatment/ enhancement distinction is that it can be confusing: both interventions aimed at treating disease and ones aimed at enhancing human perfor- mance are improvements. That may be one reason why LeRoy Walters and Julie Palmer have chosen, instead of distinguishing between treat- ments and enhancements, to distinguish between health-related enhance- ments and nonhealth-related enhancement^.^ There are at least a couple of virtues to this approach. First, Walters and Palmer's distinction conveys the sense that both sorts of intervention are improvements over an existing condition: one is health related and the other isn't. Second, the category of health-related enhancement is large enough to accommodate treatment and prevention-a virtue for those who worry that "enhancements" aimed at preventing disease (such as vaccines) will be pointed to as a way to undermine altogether the notion that enhancement is a class worthy of special attention. The downside is that the new version of the treatment/enhancement distinction may obscure the fact that the health-related enhancement/nonhealth-related enhancement distinction carries very similar difficulties (for example, what is the difierence between health- and nonhealth-related traits?) and thus just postpones having to deal with them. While our group did not reach any consensus about this matter, it may be that rather than try to craft a single term such as health-related enhancement to encompass treatment and prevention, we should just concede that we need to add to the categories treatment (of disease) and enhancement a third: prevention (of disease)."

A second, widely discussed ~roblem with Daniels's account of the treatment/enhancement distinction is that it can appear to be arbitrary.

6 Erik Parens

To make that point, David B. Allen and Norm Fost offer the follow- ing scenario:

Johnny is a short eleven-year-old boy with documented growth-hormone deficiency resulting from a brain tumor. His parents are of average height. His predicted adult height without growth hormone (GH) treatment is approximately 160 cm (5 feet 3 inches). Billy is a short eleven-year-old boy with normal GH secretion according to current testing methods. However, his parents are extremely short, and he has a predicted adult height of 160 cm (5 feet 3 inches)."

Johnny's shortness is a function of disease and thus, on Daniels's account, descrvcs treatment. Billy, however, has a normal genotype, one that produces normal levels of GH. Thus Billy's shortness is not a function of disease, and on Daniels' account does not deserve treatment.

Whle Johnny and Billy are different with respect to GH secretion, they are similar in that both will suffer equally from being short in a culture that values tall stature. Thus one might ask, does the treatment/ enhancement distinction obscure our res~onsibilitv to res~ond to the

1 J 1

suffering of both-regardless of the fact that one has a disease and one is healthy? Assuming for the purposes of argument that GH would be equally effective in both cases, would we make a mistake if we said that giving GH to Johnny would be a treatment, but giving it to Billy would be an enhancement?

Whle Daniels acknowledges that this is a hard case, he argues that his normal function model remains the best alternative for those trying to articulate a basic package of health care. In the end, he reminds us-tha; his model assumes that different individuals have different capabilities and traits. The purpose of medicine is not to eliminate all differences. Rather, it is to restore people "to the range of capabilities they could be expected to have had without disease or disability" (p. 124), given their draw in the so-called natural lottery. Thus whle Johnny and Billy are a hard case for those who in general are committed to responding to suffering, treating Johnny and Billy as the same would produce a still larger problem. Treating them the same would entail undermining our fundamental commitment to preserving differences, to promoting the health of populations made up of people whose normal function takes different shapes. If we abandoned Daniels's account of the proper purposes of health care, he argues that we would have to accept the still more problematic aspiration to level all differences to the extent

Is Better Always Good? The Enhancement Project 7

that we can. At least for many who reject the aspiration to level such differences, Daniels's argument is persuasive.

There is another problem with the normal function version of the treatment/enhancement distinction, which Eric Juengst raises,'> for which there may not be as clear a response as there was to Allen and Fost's. The normal function account runs into conceptual trouble when it is applied to "a limitlessly beneficial personal enhancement like moral sensitivity, intellectual acumen, or social grace." Juengst points out that on Daniels's own account, the notion of species-typical functioning is not merely a statistical notion, but implies a theoretical account of the design of the organism (that describes the "natural functional organization of a typical member of the species"). Juengst suggests that-statisti- calh-it may be possible to draw out a spectrum of human psychosocial capacities, with an average middle term. Theoretically, however, i t is very difficult to know what species-typical moral sensitivity, intellectual acumen, or social grace is. Thus, the species-typical functioning account doesn't provide definitive guidance in those cases where we are talking about the prospect of enhancing such capacities. And thus even if one accepts that the treatment/enhancement distinction is not arbitrary when it comes to some physiological functions like heart rate or growth hormone secretion rate, it is not easy to know how far the normal function model can get us with psychosocial functions like moral sensitiv- ity or social grace.

There are not only problems with the intelligibility of the distinction itself. According to Anita Silvers, another problem with the distinction between treatment and enhancement is that it presupposes a notion of, and inadvertently valorizes, "the normal."13 She suggests that the usual deployment of this distinction presupposes that to "promote equality of opportunity we must create a system that restores inferior individuals to average competence." On her view, a commitment to equalizing opportu- nity through "normalizing the functionality of those who have hsabilities" invites coercive and costly practices. One can read Norman Daniels's account of the importance of species-typical functioning upon which her argument depends differently from the way she does, and still accept the seriousness of the concern about the inadvertent valorization of "the normal." Indeed, in fairness to Daniels, it should be said that he is committed to trying to secure for individuals a range of opportunities, not to replicating specific forms of function-and not instead of securing better compensatory measures.

8 Erik Parens

Nonetheless, it is important to grant the possibility that the treat- ment/enhancement distinction and the conception of normality upon which it depends could be used for coercive purposes. That conception of normality was in fact used, for example, when people who were post-polio were forced to use braces so that they could approximate "normal function"--rather than allowed to use (what in most cases would have been far more helpful) wheelchairs. But to grant h s possibility suggests that we need to be on guard against this pernicious use of the distinction; it does not foreclose using it altogether.

There are at least two more important that will attend any attempt to employ the treatment/enhancement distinction to de- scribe the proper domain of medical practice and/or insurance reim- bursement. The first is that any individual's or any group of individuals' attempt to articulate a distinction like the treatment/enhancement one will, like all distinctions, take on a life of its own-regardless of the care with whlch someone like Daniels lays it out. Whereas Daniels employs the distinction with a view to providing people with what they need (a basic package of care), David Frankford's fundamental wony is that it will be used to keep people from getting what they need.

Frankford suggests that "students of public policy have long known that policy is rarely implemented as f~rmulated."'~ The danger of a group such as ours malung a policy statement about any version of the treatment/enhancement distinction is that, to begin with, "a statement that formulates a treatment/enhancement distinction potentially makes that distinction 'real.' " The problem with such a distinction becoming "realn is that it will mesh all too well with our current discourses about health policy, which "stress technical efficiency, and technical efficiency as a means to increase the size of the overall pie: the greatest goodies for the greatest number-utilitarianism (but nodung like sophisticated hybrid consequentialist models that attempt to account for distributive concerns)." That is, a version of the treatment/enhancement distinction like Daniels articulated in the hopes that it might do work in a sophisti- cated consequentialist scheme might in fact be appropriated by others and used for purposes very different from those intended by him. No matter how much we hope that we can specify our concerns about distributive justice, and no matter how much we specify our understand- ing of the tentative and problematic nature of the terms treatment and enhancement, they will be wrenched from the context in which we have articulated them.

Is Better Always Good? The Enhancement Project 9

In spite of his profound reservations about the uses to which the distinction will be put, Frankford acknowledges that it is already part of our "intersubjective use." This notion leads him to suggest that the way to minimize the potential for abuse is to try to limit our employment of the distinction to our conversations with medical professionals. Differ- ent from insurers, who on his view will surely tear the distinction from its "ethical mooringsn and sweep it "into a sea of cost containment," he hopes that the distinction might be more thoughtfully used by medical professionals, who, as practitioners of "the art of the particular," attend to particularity and context. He concludes, "administration of a treat- ment/enhancement distinction in professional practice stands a much greater chance of being highly contextualized and incorporating all of cognitive, aesthetic, and ethical practical knowledge, than would administration of the distinction in the 'policy' world of contracts and health insurance."

Even if, in the age of managed care, one is skeptical about how clear the distinction is between insurers and medical professionals, Frankford's fundamental worry about the distinction being used to keep people from getting what they need will not go away. Whoever wants to wield the distinction needs to be committed to fighting the sorts of abuses he fears.

Last but not least, there is another practical difficulty with Daniels's view that the normal function version of the treatment/enhancement distinction can be used to help articulate a basic package of care. Assuming that one of the reasons we like the treatment/enhancement distinction is that it helps us to articulate such a package, it will be important to remember the following problem. The distinction does not square perfectly with current insurance practices that many of us take to be just nor will it square perfectly with what many of us would take to be a basic package of care. As Dan Brock points out, some treatments (for example, autologous bone marrow transplants for meta- static breast cancer) are not now covered by some insurance plans because they are deemed experimental and not cost effective." Further, much insurance does cover some services that are not treatmenb, such as abortion. Finally, on Brock's account, some enhancements are covered by insurance because they prevent disease (for example, vaccination "enhances" normal immune system function). Parenthetically, as I men- tioned above, it seems to me that it is not helpful to refer (as Brock does here) to vaccinations as enhancements; such interventions would

10 Erik Parens

fall directly into the prevention category if we could agree that we need a h r d category in addition to treatment and enhancement.

Regardless of where one comes out on the prevention question, it is clear that there is neither a perfect match between treatment and what insurance does or should pay for, nor between enhancement and what insurance does not and should not pay for. The absence of such a perfect match is a limitation for those who want to use the distinction as one part of their attempt to define a basic package of care.

In sum, like most distinctions, the treatment/enhancement distinc- tion is fraught with problems. If, however, we recognize these problems, then we can use the distinction as one way to begin conversations about what doctors should and shouldn't do and what just systems of health care should and shouldn't reimburse. But as the foregoing discussion of the conceptual and practical problems suggests, it would be a mistake to think that it will be possible in some straightforward manner to read off the distinction itself what we should and shouldn't do. There is a big difference between hoping that a given distinction can begin conversation, and thinlung it can end one.

In the current context, where there are financial incentives to provide fewer services, recopzing these problems should make us wary of decisions to refuse services based on the distinction. At the same time, critics of such cost savings should realize, as does Kathy Davis in her contribution to the collection,16 that a nuanced conception of the distinction could in principle be used to help us begin to identlfy what we owe to each other. It could be one tool used to say what is and isn't included in a basic package of care.

The Schmocter Problem So far I have said how the treatment/enhancement distinction tends

to be used by those who want to identify the proper goals of medicine- and ultimately the proper constituents of a basic package of health care. I have also identified several problems associated with that goals of medicine approach and the normal function model upon which it de- pends. But even if the normal function model and the treatment/ enhancement distinction were without limitations, even if we could clearly identify the important exceptions and caveats to the rule that medicine is only for the sake of treatment, we still would not yet have the theoretical resources we need to deal with concerns about what I have previously called the goals of society.

Is Better Always Good? The Enhancement Project 1 1

To appreciate this point, i m a p e for a moment a group of people who call themselves schrnocters, a term coined by my friend and former colleague James Lindemann Nelson. l 7 Schrnocters don't claim to practice medicine. They widely advertise that they practice schrnedicine. That is, they are expert in using new biotechnologies to enhance human capacities and traits, and they sell their expertise to willing, indeed, enthusiastic purchasers. Like some plastic surgeons today, these schrnocters of the future don't rely on insurance reimbursement to make a living. More than enough people are eager to buy their services. Thus, even if talk about the "goals of medicine" could dissuade doctors from providing some services on the grounds that they are enhancements, and even if insurers refused to reimburse "enhancement" services, there is no good reason to think that schrnocters would be dissuaded from providing those services. By definition, schmocters don't care about the goals of medi- cine, they care about the goals of schmedicine. The argument that appeals to the goals of medicine to shore up a prohibition of doctors pursuing enhancement would not suffice to prohibit schrnocters from pursuing the same.

Enhancement and the Goals of Society

Thus while the treatment/enhancement distinction makes sense in the context of the goals of medicine conversation, it does not make sense in another sort of conversation. And that is the sort of conversation that we will increasingly have to have: one about what we might call the goals of society. In this sort of conversation, one can't argue against a particular intervention on the grounds that it is not a treatment or not consistent with reasonable insurance practice. The problem is harder. In this sort of conversation, if one wants to claim that a given "improve- ment" will in some contexts be problematic, then one will have to argue that it is inconsistent with or undermines some important social value or goal. And that is a difficult sort of argument to wage.

It is important to notice just how disinclined many of us are to take such an argument seriously. Such disinclination is often articulated in variations on what I will here call the arguments from precedent. The conclusion of those arguments is that wariness about the prospect of aiming new technologies at enhancement is a familiar but unfortunate form of anxiety that does not deserve to be taken seriously. I will try to show that one of the problems with those arguments is that they do

12 Erik Parens Is Better Always Good? The Enhancement Project 13

not appreciate the moral difference that new biotechnological means can make.

Means Mat t e r Morally To begin with, means make an obvious moral difference when a

given socially valued activity is predicated upon their use. As Dan Brock puts it in his contribution to the project, "In many valued human activities, the means of acquiring the capacities required for the activity are a part of the very definition of the activity, and transforming them transforms, and can devalue, the activity itself." Even when two different means are "in themselves" morally unproblematic, one means might not be a part of the definition of the activity, and thus using it would undermine the activity. For example, using a memory-enhancing drug might be morally unproblematic as a means to increase one's capacity to memorize poetry; but using the same means to gain an advantage in a chess match would be problematic insofar as the institution of chess does not allow for such means in its self-dehtion."

But means can also make a moral difference in less obvious ways. As I have already noted, there is something indeed odd in worrying about aiming technologies at the "enhancement of human capacities." What after all is worrisome about improving a human capacity? Because enhancing human capacities is taken to be a fairly self-evident good, worries about it are often dismissed as being a function of unnecessary anxiety or fear about the new.19 The arguments used to dismiss such anxiety are variations on what I have called nrgumentsjom precedent.20

Whle the argument is never put in such explicit form, its implicit structure is something like this: We've always used means A to achieve end A; means B also aims to achieve end A; therefore means B is morally ~n~roblematic. For example, we've always increased the teacher/child ratio and reduced class room size (means A) to enhance student perfor- mance (end A); Ritalin (means B) also aims to aclueve enhanced student performance (end A); therefore using Ritalin is morally unproblematic.

There are at least two sets of problems with this tendency of thought or form of argument. The first has to do with treating different means as morally the same; the second has to do with treating different ends as morally the same.

The first problem with treating different means a$ morally the same is that doing so can entail ignoring the important fact that different means sometimes work on what might be called different "objects." To use the previous example, whereas means A (increasing the teacher/

student ratio and reducing class size) changes the child's environment to enhance student performance, means B (ktalin) changes the child's b i o l o ~ . While doing the former is not self-evidently any more morally unproblematic than the latter is problematic, different means obviously will produce different sorts of experience for the child; at a minimum, one experience entails talung medication and the other entails learning with fewer classmates; one experience entails reduced "noise" in the child's brain, the other reduced noise in her classroom.

Indeed, some new means that work on our bodies instead of our environments may incline us to ignore the complex social roots of the suffering of individuals. And the easier it is to change our bodies to relieve our suffering, the less inclined we may be to try to change the complex social conditions that produce that suffering. As new biotechnological means enable us to respond to suffering that results when some humans are subjected by others to hostile and unfair condi- tions (such as overcrowded classrooms and overheated markets), we must be careful to attend to the difference that means can make.

Another problem with this version of the argument from precedent, intimately related to the first, is that it ignores the fact that different means can embody and/or express different values. For example, in her essay, "Aspirin for the Mind? Some Ethlcal Womes about Psycho- pharmacology," Carol Freedman compares Prozac and talk therapy as Werent means aimed at relieving psychical pain.2' According to Freed- man, whereas the psychopharmacological means are embedded in a mechanistic conception of the self, talking therapy is embedded in a much different and richer conception. As she puts it, what is at stake in how we treat psychical pain "is a conception of ourselves as responsible agents, not machmes." On this view, if we think that emotional problems are rooted in our interpretations of our experience, then, as animals capable of insight,

we should have a basic commitment to addressing those problems with insight and understanding. Otherwise, we are not respecting what it is to be a self. For central to maintaining the idea of a self is the commitment to regard some of our actions and attitudes as justified by our reasons, not expIained in mechanistic terms.

To give up the idea that sometimes we act based on our reasons and ; interpretations would be to give up the idea that we are responsible

for what we do. Opting only for the pharmacological, mechanistic , response lends itself to our thinking of ourselves more and more in

14 Erik Parens

mechanistic terms--and less and less in terms of being responsible agents. Thus the argument from precedent can sometimes obscure the difference that a gven means makes for how we dunk about and value ourselves.

Arguments from precedent can also obscure the fact that different means can produce en& that appear to be the same, but in fact are the same with respect to only one measure. As Ron Cole-Turner points out, while prayer and Prozac may both increase serotonin levels, the end-states achieved by those different means are only the same with respect to that one measure.22 We are mistaken to assume that the ends at whch the means aim are equivalent in all morally significant ways.

Intimately related to that problem is another. Arguments from precedent can also mistakenly assume that the ends are relevantly similar when in fact the magnitude of the change effected by the two means is radically different. That is, these arguments can ignore the moral difference that the magnitude of the change achieved by the new means can make. It is true, for example, that humans have for a long time tried to shape their progeny. Enhancement germ-line enpeering is "just like" matchmaking in that the end of both "procedures" is to influence the shape of offspring. But to say that the procedures are morally the same requires ignoring that they achieve results with vastly different degrees of precision. The degrees of precision are so dfferent that they are arguably different in kind. Again, whle this difference does not say that the more precise procedure is morally problematic,23 it does suggest that we should attend to the difference that magnitude can make-as well as attend to the respects in which ends that appear to be "the same" are not.

In sum, we must be wary of arguments that too quickly assume or assert that the means-or ends-are "just the same" as the older and accepted ones. To say that the "new" means or ends may be different in ways that matter morally does not require us to defend the view that the new means or ends are unique. Just as there are probably no uniquely new social and ethical problems, there are probably no uniquely new means or ends. The issue for us is to try to get better at dscerning how unew" means or ends exacerbate "old" social and ethlcal problems.

Three primary areas of social and ethical concern were identified in the course of our project: unfairness in the distribution of resources; complicity with suspect norms; and inauthenticity and threats to self- understanding.

Is Better Always Good? The Enhancement Project 15

Concerns about Unfairness

In a recent editorial in Science, "Science in the 21st Century," President Clinton identified "four guideposts" that our country needs to remember if we are going to put new scientific knowledge to good rather than evil purposes.24 The very first guidepost is the following.

[Slcience and its benefits must be directed toward making life better for all Americans-never just a privileged few. Its opportunities and benefits should be available to all. Science must not create a new line of separation between the haves and the have-nots . . . (p. 195 1).

President Clinton's words suggest the obvious but profound problem raised by aiming new biotechnologies at the enhancement of human capacities. Those who already have economic resources will readily gain access to new technologies, and those new technologies will make them stronger competitors for more resources. Imagine a new drug or genetic technology that enabled us to sleep less and thus be more productive. Presumably, those who had access to the technology would, as a result of their newfound productivity, win more resources. Those without the resources to purchase the new technology would be that much farther behind.

Parenthetically, .we should note that it is logically possible that all

members of our society might gain access to the same technology, thereby providing no competitive or positional advantage to anyone. Given the current situation in the United States, however, where there is not even universal access to treatment, the chances of universal access to enhancements (with siElruficant financial costs) seem rather dim. But - if there were universal access to enhancement, then we would be faced with what Dan Brock calls "self-defeating enhancements." If everyone achieved the same relative advantage with a given enhancement, then ultimately no one's position would change; the "enhancement" would have failed if its purpose was to increase competitive advantage.

Back in the "real world" of U.S. public policy, some will surely ask, Why shouldn't new science and technology make life better "for only a privileged few"? Isn't that what new science and technology have always done? This form of the argument from precedent is as regularly invoked as it is corrupt. There are many things that we've always done that we think we ought not to do either now or in the future. Exploiting and oppressing others are two.

16 Erik Parens

Moreover, as suggested above, it is naive to believe that all new biotechnologies are just more of the same. To make that point, perhaps it is useful to make a crude distinction between purchasing new tools and purchasing new capacities. In the past the rich have had access to new technological tools that enabled them to increase their productivity and thus their resources. Access to the tool that is the printing press, for example, no doubt conferred a competitive advantage on those who could afford access to it and its products. But how much one could benefit from those new tools and products was to some extent limited by one's draw in the genetic lottery. (It goes without saying that how much one could benefit was also limited by other things, like one's upbringing.) If one got a "good genetic draw" and was good at using printed materials, then presumably one would prosper better than somebody else with the same genetic draw but without access to those products. One of the new things about the new biotechnologies is that one's draw in the genetic lottery does not pose the same sort of limitation. Now, in addition to buying access to the new technologies (like print), we have the prospect of people purchasing, as it were, a better genetic draw. Thus having resources makes one a doubly strong competitor for new resources. Again, the distinction between purchasing new tools and purchasing new capacities is crude and definitely not an argument for never letting individuals purchase new capacities. But bearing the distinction in mind may help us resist those arguments from precedent that are waged to dismiss concerns of the sort articulated by President Clinton.

From a public policy point of view, it is unfortunate that even if we were all persuaded that some enhancement technologies ought not to be for sale on the grounds that they would confer an unfair competitive or positional advantage, a significant problem would remain. As Dan Brock has pointed out, in many real cases "enhancements will in part confer competitive or positional advantages on those who obtain them, but In part also constitute intrinsic goods that confer noncompetitive benefi ' t~."~~

Brock gives the example of a drug that improves concentration. Presum- ably, such a drug could confer both a competitive benefit (one would be better able to concentrate and thus better able to perform on everything from taking tests to betting on the market) and also confer a noncompetitive benefit (one would be better able to concentrate and thus enjoy Shakespeare or Schubert). As Brock puts it, "The complexity for ~ub l i c policy would be that concerns about fairness . . . would

Is Better Always Good? The Enhancement Project 17

support some limits on the use of this enhancement, but these limits would at the same time be criticized as denying individuals the possibility of gaining significant, intrinsic benefits."

To a reluctant consequentialist like myself, the notion of "intrinsic

benefits" is not transparent. Even though I am somewhat skeptical about the suggestion that some people will ~urchase biote~hnolo~ical enhancements because they want the "intrinsic benefit" of reading Shake- speare (as opposed to the extrinsic benefit of reading Shakespeare faster so that they can perform better on tests and thus ultimately in the market), I take Brock's point. The argument will be made that these technologies are desired not only because they provide a competitive advantage, but because they are good in themselves. How to adjudicate such questions will be one of the harder problems for policymakers in this arena.

Whle concerns about distributive justice are profoundly important, our project spent relatively little time on them. Those who want to think more about distributive justice and unfairness would do well to start with Maxwell Mehlman and Jeffrey Botkin's Access to the Genome:

The Challenge to Equality (Georgetown University Press, 1997).

Concerns about Complicity

A considerable amount of our group's energy was spent thinking about the problem of what Maggie Little called "complicity with harmful conceptions of normality" (where by "normalityn she refers not to any putatively value-free biological notion but rather to an altogether value- laden cultural notion).26 It was during our exploration of cosmetic surgery that we got the clearest idea about how certain enhancements might exacerbate the problem of complicity with such conceptions. That exploration entailed attempts to understand the extent to which we are free to avail ourselves of biotechnologies that relieve our individual suffering; the extent to which our choices to use those technologies are constrained by social forces; and the extent to which we are responsi- ble to criticize and resist using those technologies that relieve the suffering of incbviduals (on the grounds that they reinforce or are complicit with the social forces that create that suffering).

One of Kathy Davis's great contributions was to show the respects in which women's choices to undergo cosmetic surgery are free and that such surgery is often undertaken to relieve real suffering. Though

18 Erik Parens

her focus is indeed on women's agency, she never forgets the extent to which women are constrained in their decisions t o change the shape of their bodies. She observes,

Women's relation to their appearance is constrained by cultural definitions of feminine beauty. Cosmetic surgery can only be a viable option in a context where medical technology makes the surgical alteration of the body both a readily available and a socially acceptable solution to women's problems with their appearance. Women's willingness to calculate the risks of surgery against its benefits can only make sense in a context where a person is able to view her body as a commodity, as a possible object for intervention-a business venture of sorts.27

But rather than emphasize the need to remove or transform those constraints, Davis explores how, within those constraints, "cosmetic surgery enable[s] women to become embodied subjects rather than objectified bodies" (p. 161). That is, Davis stresses the extent t o whch, with a view to relieving their own suffering, women freely choose to reshape their bodies. "For a woman whose suffering has gone beyond a certain point, cosmetic surgery can become a matter of justice-the only fair thing to do" (p. 163).

One of Susan Bordo's crucial contributions t o our project was to show and emphasize the extent to which women's choices to avail themselves of "enhancementsn are constrained.'' Bordo spends as much time and energy attending t o the social forces exerted on women as Davis spends on their decisionmaking processes. In particular, Bordo focuses on the forces exerted by the images that the movie and advertising industries create to sell their products. Alluding to the movie Braveheart and the shoe company Nike, Bordo nicely sums up her critique:

The worst thing, in the Braveheart/Nike universe of values, is to be bossed around, told what to do. This creates a dilemma for advertisers, who somehow must convince hundreds of thousands of people to purchase - - the same product while assuring them that they are bold and innovative individualists in doing so. The dilemma is further compounded by the fact that many of these products perform what Foucault and feminist theorists have called "n~rmalization.~ That is, they function to homogenize our diversity and perpetuate social norms, often connected to race and . A

gender. This happens not necessarily because advertisers are consciously trying to promote racism or sexism, but because in order to sell products they have to either exploit or create a perception of personal lack in the consumer. . . . An effective way to make the consumer feel inadequate is to take advantage of values that are already in place in the culture. For

Is Bet ter Always Good? The Enhancement Project 19

example, in a society where there is a dominant (and racialized) preference for blue-eyed blondes, there is a ready market for blue contact lenses and blonde hair-coloring. The catch is that ad campaigns which promote such products also re-glamorize the beauty ideals themselves. Thus they perpetuate racialized norms.

Bordo shows the extent t o which advertisers teach us what our concep- tions of ourselves and our life projects ought to be. She dunks that Davis is mistaken about the extent to which we are free to choose what to do with our bodies. "There is a consumer system operating here, which depends upon our perceiving ourselves as defective, and which will continually find new ways to do this. That system-and others which are connected to it, generating new technologies and areas of expertise organized around the diagnosis and correction of 'defect'- is masked by the rhetoric of personal empowerment."

Again, whereas Davis attends to cosmetic surgery as a means with which women can relieve their own suffering, Bordo attends t o it primarily as a source of suffering. "Cosmetic surgery is more than an individual choice; it is a burgeoning industry and an increasingly norma- tive cultural practice. As such, it is a significant contributory cause of women's suffering, by continually upping the ante on what counts as an acceptable face and body."

If we are going to take seriously the respects in whch our actions are and are not free, the extent to which our life projects are and are not our own, and the extent to which we must hold ourselves and each other responsible for the values propagated by our uses of new biote~hnolo~ies aimed at "enhancement," then it would help to begin thinking more in terms of what Maggie Little calls an ethics ofcomplicity. While Little's discussion grows out of reflections on enhancement and " the doctor-patlent relationship, it can also help us think about the schmocter- consumer relationship. That is, even if we had no worries about how a given enhancement might undermine or violate the goals of medicine, we would still be concerned that it would promote complicity with harmful societal conceptions of normality. Whether doctors or schmoct- ers are the providers, what is crucial is the relationship of the "providersw and "consumersn t o the system of norms that the enhancement aims to fit.

But let us begin where Little does, with a description of the "suspect systemn of norms and practices with which both physicians and patients can be complicit. To help characterize that system, Little provides

F examples that help to distinguish among "levelsn of suspect norms.

22 Erik Parens

grabs]; say, an accountant living in Downers Grove, Illinois, who comes to himself one day and says, Jesus Christ, is this it? A Snapper lawn mower and a house in the suburbs? Should you, his psychiatrist, try to rid him of his alienation by prescribing Prozac? Or do you secretly think that maybe, as bad off as he is, he is better off than his neighbors? Because even though he's in a predicament, at least he's aware of it, which is a lot better than being in a predicament and thinlung you're not.

Why might anyone object to relieving real suffering if the means are at hand? Elliott suggests that if you want to answer that question you need to grasp two features of what he, following Lionel Trilling and Charles Taylor, calls an ethics of authenticity. First, you need to notice that many of us think of our lives as a project. The notion of life as a project depends upon the idea that "the sense or significance of our lives depends on how we live them." And that idea in turn depends upon the idea that to some extent our lives 'Lare planned undertakings which, to a large extent, we control and for which we are responsible."32 The second feature of the ethics of authenticity that we need to grasp is that to answer the question, How should I live? one has to look inward. "You have to be true to yourself."

But with the aspiration to authenticity comes the possibility of inauthenticity, the possibility of not leading one's own life. On Elliott's account, the fear of such inauthenticity motivates much of the concern about drugs like Prozac. Prozac may relieve my unhappiness, but it is my unhappiness. It is the unhappiness into which I have grown, and it is the unhappiness with which I want to make my peace. "It would be worrying if Prozac altered my personality, even if it gave me a better personality, simply because it isn't my personality."33

Whereas many Americans are committed to the idea of authenticity, it may be that many more of us are committed to the related but distinct idea of selJfuljl1ment. As Weber argued in The Protestant Ethic and the Spirit o f Capitalism, for those who Live in Luther's wake, work takes on a moral character. It becomes a calling. Not being devoted to it is a moral failing. And as Elliott observes, this idea gets played out in interesting ways in America. "What Luther referred to as a calling [to God] survives nowadays . . . as a calling from within: the idea of discovering yourself, of finding your own particular place in the world. A meaningful life . . . is something that you discover and create on your own, especially through the l$e o f work and the ltfe o f family and household " (emphasis added).

Whle Elliott entirely appreciates the virtues of thls worldview, he observes that for many of us it comes to mean that if we are not

Is Better Always Good? The Enhancement Project 23

aggressively pursuing prosperity and happiness with the fervor urged by our founding fathers, then we are letting ourselves down and squan- dering our time on earth. Given that many of us Americans feel it is our duty to pursue self-fulfillment and happiness on the Weberian model, it would not be surprising if many of us came to feel it our duty to use any means possible to fulfill it-including taking drugs like Prozac. (Note that we're not talking here about using drugs like Prozac to treat clinical illness.)

For those committed to the idea of authenticity, using drugs to pursue the idea of seCf-fuJillment is disturbing. That of course is not the ground for an outright prohibition of the use of such drugs for such purposes. But appreciating that drugs like Prozac are good at promoting self-fulfillment as opposed to authenticity is useful if one wants to remember that such drugs are not "a11 purpose means." These drugs are not good for simply any life project. They are good for a particular sort of life project.

To Peter Kramer's credit, he is acutely aware of, and writes about, the extent to which Prozac might be seen to promote the "virile values" of a capitalist society. Yet in the end Kramer stands by his claim that Prozac is a "feminist drug," whlch, when prescribed by a wise doctor and in conjunction with talk therapy, can be used by women (and men) to promote whatever life projects they see as fit. To make vivid what he has in mind when he speaks of the wise doctor who can help his patients pursue whatever life project they want, he invokes the image of Dr. Yang in Woody Allen's movie Alice. In invoking Dr. Yang and Alice, Kramer seems to forget what life project Alice decides to pursue after she is aided by the wise doctor and h s drugs. Different from nearly all of Kramer's patients, who become better at pursuing the sort of life projects currently valorized by our culture, Alice rejects those projects and that culture. With Mother Teresa as her model, Alice gives up her life of unfettered consumption, and commits herself to a life of poverty and charity.

We are so deeply embedded in our own way of life that many of us find it impossible to imagine that it is a very particular kind of life. If we value critiques of and departures from those conceptions of the "normal life project," then we are going to have to get much better a t noticing when a drug is promoted as being good for any life project, but is in fact good for only one (albeit widely acclaimed) sort. Inauthen- ticity is not a new problem, created by technologies aimed at the enhancement of human capacities. But with the power of these new pharmaceuticals comes the potential to exacerbate that old ~roblem.

24 Erik Parens

Whereas Elliott was concerned that certain "enhancements" might promote a turning away from a form of anxiety or feeling bad that is constitutive of a life lived courageously and authentically, project participants like Gerald McKemy and Mary Winkler were concerned that some "enhancements" might promote a turning away from the vulnerability, imperfection, and finitude that is constitutive of life alto- gether. As Gerald McKemy puts it, "To the extent that enhancements overcome, or lead us to deny, the vulnerability of the body, they also foreclose the lunds of self-formation that our awareness of vulnerability makes possible."34 Along similar lines, Mary Winkler argues that our advertising practices reveal the depth of our desire to gain control over what, ultimately, is beyond our control: the fact of our own finitude.35 That is, our desire for control and stability put us at risk for missing what Winkler calls our "full humanity." We risk forgetting that we are ultimately and essentially vulnerable creatures.

While McKemy and Winkler both worry that "enhancement tech- nologies" may promote our tendency to forget or ignore what sort of creature we really are, neither of them thinks that such a worry should preclude our talung seriously the desire for "enhancements." As Winkler generously puts it, when talking somewhat skeptically about some cosmetic surgeries, "I would not ignore the desires of any-they are all human desires."

Surely the sorts of turning away from fundamental life experiences worried about by Elliott, McKemy, Winkler, and others, are not new. Inauthenticity is not a new problem, created by aiming biotechnologies at the enhancement of human capacities. Though inauthenticity may not be a new problem, it is one that new "enhancementsn have the potential to exacerbate.

Considerations for Public Policy

If the deliberations of the project working group did not lead to specific policy recommendations, they did make clear the considerations that are essential for thoughtful policymaking with regard to the use of new technologies to "enhance" human capacities and traits.

It would be a mistake to think that the treatment/enhancement distinction

will ever provide good, transparent moral guidance about the particular decisions faced by individuals such as doctors or institutions such as managed care companies. The distinction should not be looked to for transparent guidance about whether a doctor should use a given means

Is Be t t e r Always Good? The Enhancement Project 25

to relieve a given individual's suffering-or about whether a managed care company should provide such means. Like many distinctions, the treatment/enhancement distinction is permeable, unstable, and can be used for pernicious purposes. If used carefully, however, it can be one tool to start important conversations about the sorts of health care services that a just system of health care should provide.

It would be a mistake to think that the new biotechnologies are just more

o f the same. We should give up the arguments that take the form, "we've always done it." It is true that we have always sought enhancement. But arguments from precedent glibly excuse us from thinking about how new means to achieve old ends make a moral difference. Worrying about technologies aimed at the enhancement of human capacities and traits is not the same as worrying about apple pie.

The term enhancement can alert us to and start conversations about

the potential for exacerbating long-standing problems such as unfairness, complicity, and inauthenticity .

We must all become cognizant of the fact that "enhancements" have the potential to widen the gap between the haves and have nots. Making policy in light of that concern will always be made difficult by the fact that some of the new biotechnologies will offer both a competitive advantage and a noncompetitive (or "intrinsicn) advantage. A drug that could truly enhance memory is an example of such a biotechnology. In spite of that difficulty, it will be extremely important for policymakers to-become in- creasingly aware that these new biotechnologies have the potential to widen the gap to an unprecedented extent. Further research is needed to come up with strategies to avoid putting new biotech- nologies to purposes that will widen the already huge gap between the haves and have nots. We must all become vigilant about knowing when new "enhance- ments" are complicit with harmful conceptions of normality. The enormous problem here is that it requires understanding our motivations as consumer-citizens. When are we availing ourselves of a biotechnology because we have been duped by a dominant norm, and when are we availing ourselves of it because we're trying to play with the system or enter that system to change it? Research is needed to create educational strategies that would enable individuals to engage in the sort of self-exploration that could help them reach decisions about "enhancements" in a more truly lnformed way.

26 Erik P a r e n s

While some forms of enhancement in some contexts may obviously be problematic, many more will not be. As long as we are committed to relieving suffering, and such technologies are a means to do that, we will always have good reason t o employ them. The great challenge is to find ways t o relieve such suffering that do not perpetuate harmful conceptions of normality. The challenge is to learn simultaneously to attend to the suffering of individuals and t o criticize and resist the systems that produce

that suffering. W e must all become vigilant about noticing that whereas many new biote~hnolo~ies will be marketed as "all purpose means," they may not be. Many will be good only for one currently valorized but narrow sort of life project. Even if there were notlung wrong with the dominant conceptions of a good life that reign in our culture today, there would be something wrong with pretending that those are the only worthy conceptions-or that the means which advertisers want to sell us are "good in them- selves." Further research is needed to develop strategies to provide individuals with opportunities to recognize the difference between

means that are truly "all purpose" and ones that are just advertised that way.

Finally, 1 would advise that those who follow our project into the enhancement fields take on smaller and more manageable parcels of it. Our colleagues at Case Western Reserve University's Bioethics Center, for example, are limiting their study t o genetic enhancement. We here at The Hastings Center would like to study the even narrower question concerning the "enhancement" uses to which the new "antidepressants" are being put. Not only should smaller cases be taken on, but smaller policy questions need to be tackled in greater depth. We hope that our project has done some of the conceptual ground clearing that will make it easier for others to toil in these fields.

Acknowledgments

Thls essay was written with generous support from the National Endowment for the Humanities (RH-2 1271 -95). I t was first published as a special supplement t o volume 28, no. 1 (1998) of the Hastings

Center Report. 1 gatefully thank the following people for reading and

Is B e t t e r A lways Good? T h e Enhancement Project 27

commenting on earlier versions of this essay: Erika Blacksher, Dan Brock, Carl Elliott, David Frankford, Eric Juengst, Margaret Olivia Little, Carol Tauer, and Robert Wachbroit. Needless to say, the remain- ing mistakes and infelicities are mine alone.

NOTES

1. In a thought experiment, LeRoy Walters and Julie Gage Palmer ask h s question. See The Ethics o f Human Gene Therapy (New York: Oxford University Press, 1997), pp. 126-27.

2. NEH Grant number RH-21271-95. 3. James E. Sabin and Norman Daniels, "Determining 'Medical Neces-

sity' in Mental Health Practice," Hastings Center Report 24, no. 6 (1994): 5-13, at 5.

4. Norman Daniels, "The Genome Project, Individual Differences, and Just Health Care," in Justige and the Human Genome Project, ed. Timothy F. Murphy and Marc A. Lappe (Berkeley: University of California Press, 1994), pp. 110-32, at 122.

5. Sabin and Daniels, "Determining '~kdica l Necessity,' " p. 10. 6. Daniels, "The Genome Project, Individual Differences, and Just Health

Care," p. 122. 7. Sabin and Daniels, "Determining 'Medical Necessity.' " 8. For alternative versions of the distinction, see Eric Juengst, "What

Does Enhancement Mean?" h s volume. 9. Walters and Palmer, Ethics of Human Gene Therapy, pp. 110-1 1.

10. See Eric Juengst, "Can Enhancement Be Distinguished from Preven- tion in Genetic Medicine?" The Journal of Medicine and Philosophy 22, no. 2 (1997): 12542; Juan Manuel Torres "On the Limits of Enhancement in Human Gene Transfer: Drawing the Line," The Journal $Medicine and Philosophy 22, no. 1 (1997): 43-53.

11. Cited in Daniels, "The Genome Project," p. 123. 12. Juengst, "What Does Enhancement Mean?" 13. Anita Silvers, "A Fatal Attraction to Normalizing: Treating Disabilities

as Deviations from 'Species-Typical' Functioning," this volume. 14. David Frankford, "The Treatment/Enhancement Distinction as an

Armament in the Policy Wars," this volume. 15. Dan Brock, "Enhancements of Human Function: Some Distinctions

for Policymakers," h s volume. 16. Kathy Davis, "The Rhetoric of Cosmetic Surgery: Luxury or Welfare?"

this volume. 17. Nelson credits Saul Kripke's discussion of identity (and "shmidentityn),