“Pulling up the bottom”

In his paper, “Normal Functioning and the Cog enhance cartoonTreatment-Enhancement Distinction,” (abstract) Norman Daniels renders a highly compelling and thought provoking argument against drawing rigid lines to demarcate medical interventions that are considered treatments, and those viewed as enhancements.  He focuses primarily on three basic objections: that it is difficult to clearly separate treatments from enhancements, that the distinction does not give us the boundary between what is obligatory and nonobligatory in medical interventions, and that it leaves us with hard cases that make the distinction seem subjective.

To reinforce his arguments, Daniels gives several examples in support of his objections. An example points to the insurance coverage for growth hormone treatment in children who are found deficient due to some underlying medical condition such as a tumor, while children diagnosed with idiopathic short stature are not covered for treatment. While one could fairly easily rationalize why growth hormone treatment for a “naturally” short child should be considered an enhancement, it becomes trickier when Daniels suggests that perhaps “bad genes” are to be blamed for both conditions. One child is “naturally” short because he has a set of genes that make his growth hormone receptors less responsive to secretion, while the other has a set of genes that causes him to grow a tumor, which then disrupts hormone secretion. Although both children are victims of “inferior” genes, an abnormal growth caused by bad genes is viewed by society as a disease, while a short stature also caused by bad genes is considered well…bad luck.

Daniels goes on to talk about society’s “social construct” of disease and presents more thought provoking arguments. Personally, I thought that his section on “permissible-impermissible boundary” posed an enduring question. Daniels asks of our obligation to justice as a society:

“Suppose we had an intervention that might allow us to improve reading or math skills, perhaps through an effect on short-term memory, attention, or some other component of cognitive processing capabilities. Suppose further that its effect is more pronounced for those who perform in the lower half of the normal performance distribution, so that it reduces variance in reading ability by pulling up the bottom. Then, just as we would consider it remiss if educational institutions did not incorporate a pedagogical technique that had the same effects or provide a nutritional supplement that had the same effect, so too we might think medical institutions should provide the intervention, costs and resources permitting.”

The idea of enhancing normal cognitive abilities often evokes an uneasy feeling in many for several reasons. Once safety and efficacy have been established, fairness is often cited as an argument against cognitive enhancement. However, if the technology were available, safe, effective, and inexpensive, is it fair not to enhance those normal persons at the bottom? Daniels draws a parallel with enhancing immune capabilities beyond those involved in normal functioning, such as vaccinations. Taking that analogy further, people don’t seem to feel cheated when individuals considered most at risk are vaccinated first. What if cognitive enhancers only work to get every individual to his own peak performance? In other words, it does not confer an “unfair” advantage, but instead enables everyone to compete.

Over the past year since I first heard about pharmacological cognitive enhancers, my views have shifted from seeing them as completely unnecessary and unfair, to well, it depends, and often, why not? As a child, I grew up reciting poems that extolled the sense of pride that one could only get with hard work. A recent conversation with a friend was a good reminder of this, she had bought a lottery ticket for the first time ever, and she felt such shame about it…she’s been living in the States for 11 years. Still, Daniel’s remark on society’s obligation to justice seems most rational, and so in the spirit of vaccinating the most vulnerable in the populace first; in the spirit of iodized salt; in the spirit of special education; society has an obligation to “pull up the bottom” provided cognitive enhancers are safe and effective.


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