PCBE: Beyond Therapy: Biotechnology and the Pursuit of Happiness (Superior Performance)

Human beings desire not only "better children," we desire also to be better ourselves. Aspiration, born of the attractiveness of some human good and the energizing awareness that we do not yet possess it, is at the heart of much that we do and much that is admirable about us. We strive to be better human beings and citizens, better friends and lovers, better parents and neighbors, better students and teachers, better followers of our faiths. Many of us aspire also to excel in the specific activities to which we devote ourselves; and nearly all of us admire superior performance whenever we encounter it, even in areas where we ourselves are only mediocre.

Superior performance is pursued in a myriad of human activities. The athlete strives to run faster, the student to know more, the soldier to shoot more accurately, the vocalist to sing more musically, the chess-player to play with greater mastery. Our motives for seeking superior performance are varied and complex, as human desire and human aspiration always are. We seek to win in competition, to advance in rank and status, to increase our earnings, to please others and ourselves, to gain honor and fame, or simply to flourish and fulfill ourselves by being excellent in doing what we love. In pursuing superior performance, human beings have long sought advantages obtainable from better tools and equipment, better training and practice, and better nutrition and exercise. Today, and increasingly tomorrow, we may also find help in new technological capacities for directly improving our bodies and minds-both their native powers and their activities-capacities provided by drugs, genetic modifications, and surgical procedures (including the implantation of mechanical devices). What should we think about obtaining superior performance through the use of such biotechnologies? That is the theme of this chapter. But before turning to the question raised by the novel means, we must begin with questions about the goal itself: "What is superior performance?"

I. THE MEANING OF "SUPERIOR PERFORMANCE"

The words themselves-"superior performance"-have many meanings, both individually and together, each of them suggestive and important. "Superior" can mean "better than I have done before," or "better than my opponent," or "better than the best." It can describe something that is universally or indisputably outstanding or something that is better only in relation to the alternatives. It can also mean-and this is especially relevant in this context-"better than I would have done without some 'extra edge' or 'performance enhancement.'" Because superiority, on whatever meaning, is time-bound and precarious, we not only seek to do better than we have done before. We also seek to maintain abilities that seem to be slipping away and to regain powers and abilities that we have lost. We want to become superior and stay superior.

Even more central to our analysis is the meaning (or meanings) of "performance." It denotes the active doing of what we do and the active expression of what we are: living embodied beings or agents, individually at-work in the world. To be alive at all means that certain organic systems are performing their functions. In the human case, active performance includes not only the autonomic activity of a well-working organism functioning without conscious choice and direction (for example, in heart beating, digesting, and normal breathing). It also includes the self-directed performance of various chosen human activities (for example, walking, running, dancing, thinking). To "perform" an activity is not just to do it, but to do it thoroughly, "through and through," to do it to completion and fullness. The idea of performance also suggests a relationship with other performers and spectators: performance before others, with others, and against others. Yet it is also possible to perform certain activities without others, on one's own and for oneself, manifesting who we are for our own enjoyment alone. Temporally speaking, a performance is both that which is done "in-the-moment" (a great shot to win the game, a great musical performance) and that which is done "over time" (a great career, writing a great symphony). It embraces that which is done effortlessly or seemingly effortlessly (Joe DiMaggio swinging the bat) and that which is done with great and obvious exertion (Pete Rose hustling to turn a single into a double). Finally, and most pertinent to this inquiry, the word "performance" sometimes means a brilliant illusion, a skilled simulation of reality, or the separation of what one does from who one is: performance as the make-believe acting of actors rather than the self-revealing doings of genuine doers. "Performance" suggests both real activity and real agency, but also the possibility of being or seeming to be something other than who and what we are.

At the core of the notion of "superior performance"-understood as an object of noble aspiration-is the idea of excellent human activity: excellent, not inferior; human, not inhuman or nonhuman; active and not passive, at-work and not idling. The reason we spend much of our lives trying to "better ourselves"-not just materially, but as athletes, musicians, soldiers, or lovers-is that we know or believe that not all performances are equal: some are higher and some are lower, some are more worthy and some are less worthy, some are excellent and some are average. But we desire to excel as human beings; we want to exercise our distinctively human powers both excellently and in our peculiarly human way. We know or believe that some performances will reveal who we are capable of being when we are at our best.ⁱ

The striving for superior performance is, as noted, central to our humanity. But it also raises a series of questions and dilemmas, and sometimes unease and concern, not only about the means we employ, but also about the goal itself. We worry that the desire to become better could deform elements of human life that are not properly measured according to the standard of "superiority," or that our improvements will be achieved only at the price of our integrity and dignity. We worry that pressures to excel will overwhelm us, or that the desire to be the best will tempt us to "cheat" our way to the top. We worry that putting such a high premium on excellence will crowd out the disadvantaged, or lead us to mistreat those who are "failures." In short, we worry about balance, fairness, and charity-but also, and perhaps more profoundly, we worry about pursuing the wrong goals in the wrong way, or posing as something we are not.

These enduring questions about the pursuit of superior performance acquire heightened visibility and greater salience as a result of emerging new biotechnological powers, present and projected, that promise to help us in our efforts. These powers are surgical, genetic, and pharmacological. Some are familiar-like steroids used to enhance athletic performance and amphetamines used to enhance mental performance. Others are novel-such as the genetic modification of human muscles. And still others are imaginary rather than real-such as genetically engineered Michael Jordans or drugs that would give us perfect memory.

Most of the performance-enhancing technologies of the future, like those in use today, will probably be developed less to aid superior performance than to treat disease and relieve suffering. Yet the broad powers of many drugs and devices make them readily adaptable to uses for which they were not originally intended. Our biotechnical armamentarium for aiding superior performance is still extremely limited. Yet we are already witnessing the wide range of activities that might be biologically enhanced. Modafinil, a drug that combats narcolepsy and induces wakefulness more generally, has been shown to enhance the performance of airplane pilots, commercial and military. Ritalin, the amphetamine-like stimulant whose use in children we discussed in the previous chapter, is also widely used by high school and college students to improve their concentration while taking the SATs or writing final exams. Viagra, a remedy devised for male impotence, is increasingly used by the non-impotent to enhance sexual performance. Growth hormone, the body's natural promoter of skeletal growth, is now being used not only to treat dwarfism but also to help the normally short to become taller. Other drugs are used to calm the nerves or to steady and dry the hands of neurosurgeons and concert pianists. These examples constitute but a small preview of coming attractions.

To fully understand the meaning of using these new biotechnical powers, in all their variety of effects and possible uses, we would need to inquire more deeply into the meaning of "superior performance" itself. We would need to explore the reasons we seek to become better, the abilities we seek to enhance, the different means we might use to enhance them, and the true character of the different activities in which we engage. We would need to pay attention both to the ends we seek and the means and manner by which we seek them, as well as the differences between given human activities, their various excellences and what it takes to attain them. And, attending to the special issues raised by the use of bio-engineered enhancements, we would need to address these central questions: As we discover new and better ways to "improve" our given bodies, minds, and performance, are we changing or compromising the dignity of human activity? Are we becoming too reliant on "expert chemists" for our achievements? Do such potential enhancements alter the identity of the doer? Whose performance is it, and is it really better? Is the enhanced person still fully me, and are my achievements still fully mine? Have I been enhanced in ways that are in fact genuinely better and humanly better? And, beyond these questions regarding individuals, we would need to consider the implications for society should such uses of biotechnology become widespread-in school, at work, or in athletics, warfare, or other competitive activities.

Needless to say, such a comprehensive examination is beyond the possible scope of this discussion. There are too many different kinds of superior performance and too many conceivable biotechnical means of enhancing the performers. To introduce the subject and to illustrate the ethical and social issues involved, we confine ourselves largely to one particular case study in one particular area of human activity: human sport. It is an activity where human excellence is both recognizable and admired, where concerns about wrongfully enhancing performance are familiar, and where disquiet about the use of "performance-enhancing drugs" is widely shared if not always fully understood. As we shall see, many of the larger questions readily emerge from this case study, and the relevance of the present analysis for other human activities should be plain. Where explicit comparisons with other human activities will prove revealing, we shall not hesitate to bring them into the picture.

II. SPORT AND THE SUPERIOR ATHLETE

At first glance, focusing on athletic excellence may seem strange. True, sports are hugely popular and exciting, and the achievements of our greatest athletes are very impressive. But is sport important? Why spend time worrying about the dignity of athletics when there are many more serious problems in the world and when many life and death dilemmas in bioethics are so pressing? Such questions raise a powerful point: many aspects of human life are indeed more significant or more worth worrying about than athletics. Nevertheless, if one is interested not only in combating human misery but also in promoting human excellence, the world of sport is an extremely useful case study. Indeed, what we learn of wider application from thinking about athletics may prove far more significant than it first appears.

For one thing, sport is an area of human endeavor where human excellence is widely admired-where we honor the best for their achievements, and where we admire the striving of those who seek to improve, achieve, and excel.ⁱⁱ Athletic excellence appeals partly because it is open, genuine, and publicly visible, inviting thousands of otherwise disconnected individuals to unite in shared appreciation. In perhaps no other contemporary activity is there such a manifestly evident and celebrated display of individual (and group) human excellence.

Second, sport is an activity that invites deeper reflection about our bodily nature, and especially our distinctly human bodily nature. After all, animals and machines can do many things much better than we can-artificial pitching machines can "throw" harder, cheetahs can run faster. But it is the human athlete that we admire. Understanding why this is so has implications far beyond athletics.

Third, sport is an area of life where we have made some effort-both cultural and legal-to preserve the "dignity of the game," so to speak, from "cheating," both biological (for example, steroids) and mechanical (for example, corked bats). But we have done so without always examining precisely how the dignity of the game or the excellence of the performance would be compromised were the use of these enhancing agents to become normal.

Thus, while we begin this analysis by acknowledging that "life is not a game," we also suggest that things essential to sport-such as aspiration, effort, activity, achievement, and excellence-are essential also to many aspects of the good human life.ⁱⁱⁱ Examining the significance of performance-enhancing biotechnical powers for human sport may help us understand the significance of such powers for excellent human activity more generally.

To be a superior athlete depends on numerous things: native gifts, great desire, hard work, fine coaching, worthy competitors, sound equipment, good luck. The types of talents needed will vary with the sport or, in team sports featuring specialization, with one's position or role. But any superior athlete requires strength, drive, endurance, coordination, agility, vision, quickness, cleverness, discipline, and daring, shared virtues of body and soul that manifest themselves in different ways and degrees depending on the activity and the way one performs it. And, in every sport, at every level of competition, superior performance matters.

Some ways of becoming a superior athlete center on the athlete himself: for example, healthy physical growth, better training, more experience. Others involve outside help: better coaches, better teammates, better competitors. Some involve improving one's equipment: fiberglass vaulting poles, graphite tennis rackets, high-tech high-tops. And others involve improving one's own body: high-protein diets, vitamin supplements, anabolic steroids, genetic modifications. These different approaches can be complementary or overlapping: better diet improves one's capacity to train, and better training improves one's body and its powers. We intuitively sense, however, that there may be a difference between, for example, lifting weights, eating egg whites, and using a graphite tennis racket, just as there appears to us to be a difference between eating egg whites and taking anabolic steroids. But if so, understanding the true nature and significance of these differences is a complex matter, not easily specified. How do the different means of becoming superior differ from one another? Is the excellence or superiority of an activity affected by the way it is done or pursued? Do some ways of improving performance change the actual character of the activity? If some performance enhancements are considered "cheating," just who or what is being cheated-one's competitors, one's fans, oneself, or the dignity of the activity itself? These are the sorts of questions we shall try to answer.

As already indicated, there are multiple ways to improve athletic performance, from the elementary to the sophisticated, from the old to the new. Consider, for example, competitive running. The ancient Greek runners ran barefoot. Then the use of shoes protected against injury. Cleats gave greater traction. Better nutrition augmented general health and energy. Weight training strengthened muscles. Regimens of practicing wind sprints or fixed-distance runs built up endurance. Competition during training provided motivation and experience. Coaching improved mechanics and strategy. High-tech shoes improved efficiency of motion. Erythropoietin injections increased oxygen carrying capacity. Anabolic steroids permitted greater weight training leading to enlarged muscle mass. Stimulant drugs aided alertness and concentration. Someday, insertion of synthetic muscle-enhancing genes may make muscles stronger, quicker, and less prone to damage.^iv Where in this sequence of devices to improve running do we acquire any disquiet regarding the means used? Why, if we are disquieted, are we bothered?

To prepare for the answers to these questions, let us look more closely at a number of different ways of improving athletic performance-some celebrated and some not, some already here and some on the horizon. They fall generally into three categories: better equipment, better training, and better native powers.

Examples of superior performance through better equipment are ubiquitous. Pole-vaulting used to be done with rigid bamboo poles and vaults of fifteen feet high seemed virtually superhuman; now flexible fiberglass poles are used, and vaults go over nineteen feet. Baseball gloves were once little more than shaped padding for the hand; now, more than twice their original size, they resemble small bushel baskets. Curved hockey sticks, replacing the straight ones, make possible greater puck control and faster shots. Graphite tennis rackets yield greater racket speed and power. With such equipment now an accepted part of the sport, used by virtually everyone in competitive and professional athletics, players who did not use them would be looked upon as foolish, and they would likely never make it to the highest levels of competition.

Yet not all performance-enhancing equipment is welcomed into sport. Corked baseball bats, for example, are believed to permit increased bat speed and thus hitting power. Yet they are considered an unacceptable form of cheating and are illegal in professional baseball. Players who use them are looked down upon by many fans as "cheaters" or seen as fools for believing they could get such an unfair advantage without getting caught. Were someone to propose that the rules be changed, so that everyone could use corked bats, many people would probably still object. Owing to the importance of history and statistics in the glamour of baseball and the desire of fans to be able to make valid comparisons of superior performance across the generations, their wish to see more home runs does not-at least for now-trump their wish to preserve the "integrity of the game." Comparing graphite tennis rackets (which we embrace) and corked baseball bats (which we decry) suggests how our objections to performance-enhancing equipment are often conventional, with differences due to traditions, chance histories, or elective decisions about the rules of the game. Some of these rules are not matters of principle but of taste, while others involve particular discernments about what is best for individual sports that cannot be universalized.

Better training can take several forms. It could become more rigorous, the athlete working harder and longer than he did before or harder and longer than his teammates or his rivals. Training could be more effective (better, not necessarily harder), the athlete training more intelligently or scientifically. And training could be better coached, the athlete practicing under the guidance of someone with superior wisdom or know-how regarding nutrition, general fitness, or specialized skills such as batting or pitching.

All of these forms of improving performance through training proceed through habituation, practice, and instruction, consciously and conscientiously undertaken. Yet the effects of the training are often written into the bodies of the athletes, in the form of increased strength, longer endurance, greater quickness, improved coordination, and smoother performance. Similar bodily changes might also be produced not through active training or active training alone, but by direct biotechnical intervention into the body of the athlete, seeking to improve his native capacities by altering his underlying genetic or biochemical make-up.

Direct biological means of improving the powers of our bodies range from the small and familiar to the large and novel. Least dramatic are special diets, for example, diets high in protein, known for decreasing body fat and increasing muscle mass. There is laser eye surgery to correct imperfect or "low-performing" eyesight, capable of producing permanent improvements in the patient's vision with a single treatment. Some prominent athletes (including Tiger Woods) have used this surgery to get "better-than-normal" eyesight, a practice that is fully legal and considered by all professional sports to be an acceptable "enhancement."

More invasive, more controversial, and (for now) illegal in competitive athletics are the uses of various drugs to enhance performance: stimulants like amphetamine to produce heightened attention and quicker reactivity; erythropoietin (EPO) to overproduce red blood cells and, hence, to augment the body's carrying capacity for oxygen (so-called "blood doping"); human growth hormone to increase height or generalized vigor; and anabolic steroids to facilitate training that will increase overall muscle mass. Off in the future, but already visible on the drawing board, are prospects of genetic enhancement of bodily strength and resilience through the insertion into muscles of genes for erythropoietin or more specific muscle growth factors. Because so much of athletic excellence is based on strength and swiftness, the muscle-enhancing technologies are under special scrutiny by the sports authorities. They are also of special interest to us. To illustrate how present and prospective biotechnologies can enhance native bodily powers, we turn next to various technological approaches to direct muscle enhancement, both pharmacologic and genetic.

III. MUSCLE ENHANCEMENT THROUGH BIOTECHNOLOGY

Our muscles are essential to human life in many ways. They are central agents of physical strength and speed, attributes admired and celebrated in most human cultures. All of our motions-from walking, swimming, and lifting, to writing, chewing, and shaking hands-depend on them. As basic elements of physicalvigor, they also play a role in human attractiveness and in our sense of well-being and even our sense of who we are. Our path through the life cycle is displayed most vividly in the changes of our musculature.

When we are young, the active use of our muscles in play and in sports strengthens and develops them. At puberty, production of estrogen and testosterone enhances these processes, so that the peak of human muscular development usually occurs between ages 20 and 30. Thereafter, the strength and size of human muscles usually declines, falling off by about one-third between the ages of 30 and 80.¹ As we age, we gradually lose the ability to dovarious physical tasks, sometimes in part, sometimes altogether.^v

There are, of course, individual variations from this general pattern. Some people suffer from muscle diseases, often caused by specific genetic mutations (for example, muscular dystrophy), that render them unable to develop their muscles to the same extent as the healthy. Others manage through exercise and fitness training to maintain peak muscular strength and endurance much longer than the average. Still others, sedentary and inactive, neglect those maintenance functions altogether and fall weaker earlier than most.

Muscles do not generate human strength and speed in isolation. They need to be physically integrated with, and function harmoniously through their attachments to, nerves, tendons, ligaments, and bones. While our attention will be on enhancing the activities of muscles and their cells, this fact reminds us that any biotechnological intervention that strengthens only muscles may unbalance the interactions with these other body parts, with serious malfunction as a possible consequence.

Though not exactly a matter of athletic performance, the perfection of our musculature and body build is a matter of great concern to many people intent on improving their body image. Muscles have always played a prominent role in the idealizations of male human form. A classical picture of excellence of the youthful male human form is Michelangelo's sculpture of David, completed around 1504. The musculature is well developed and well proportioned but without much articulation of individual muscles; indeed, the integrated physique points not to itself but to some impending action. Yet David's strength and power shine through the marble, and leave us with a mental picture of the classical ideal of muscular development and proportion, poised for graceful and superior performance.

A more contemporary idealization of the male human form is the modern bodybuilding champion, such as Arnold Schwarzenegger. Through specialized weight training, perhaps with the help of anabolic steroids, all the muscles (especially the biceps and pectoral muscles) become much larger than those in the statue of David, and the different groups of skeletal muscles are individually articulated. The picture is less one of measured and proportionate strength in the service of splendid activity, more one of "muscle-bound" power, to be admired for its own sake.^vi Yet although they differ in proportion and muscle articulation, both the classical and contemporary ideals testify to the importance of muscles in images of male strength and power.^vi

The body's appearance reveals more than a superficial image. As embodied agents of our innermost will, muscles not only work our purposes on the world, but make manifest the deep qualities of our character, our dispositions and intentions, our self-discipline, self-development, and self-image. We are highly attentive to posture and motion in others, and muscular actions make possible the communication and cooperative coordination essential for human society. All of these qualities are especially evident-and therefore visible for evaluation-in many forms of athletic performance.

Scientists have learned a great deal about the cellular structure and development of skeletal muscles, as well as about how genes important to muscle cells function and are regulated. The following brief discussion of muscle cell biology will reveal targets for biotechnical interventions aimed at improving muscle strength and resilience.

The major cell type present in skeletal muscle fibers is the multinucleated myotube, a long cylindrical cell that does the contracting. These myotubes arise from precursor cells, mononucleated myoblasts, by means of their fusion with each other and with pre-existing myotubes. Myoblasts, in turn, are formed by differentiation of a particular stem cell found in muscle tissue, called a satellite cell.²

The multiplication and differentiation of satellite cells into myoblasts is regulated by several specific protein growth factors (primarily insulin-like growth factor 1 [IGF-1] and hepatocyte [liver cell] growth factor [HGF]). This process is also influenced by hormones such as growth hormone, testosterone, and estrogen. Growth hormone secreted by the pituitary acts on the liver to stimulate synthesis of IGF-1 and its subsequent release into the circulation. (See Figure 1.)

In muscle tissue, IGF-1 binds to specific receptors on the surface of satellite cells to stimulate their multiplication, producing both differentiation of satellite cells into myoblasts as well as more satellite cells. (See Figure 2.)

Figure 2. Schematic diagram of some important processes in skeletal muscle fiber growth and repair.

Importantly, a slightly different form of IGF-1 (muscle IGF-1 or mIGF-1) is also produced locally in muscle tissue in response to stretching the muscles during exercise. This form is thought to act the same way as circulating IGF-1 does in stimulating satellite cell multiplication and differentiation. However, because mIGF-1 is slightly different in chemical structure from IGF-1 produced in the liver, mIGF-1 apparently does not enter the circulation, so its effects can be restricted to promoting growth and repair of muscle tissue locally.

We can now see how attempts at muscle enhancement might work. As has long been known, exercise increases muscle size and strength. Exercise both transiently damages muscles and, in response, causes them to increase in size and strength. Exercise (muscle stretch) increases the production of a specific locally active form of insulin-like growth factor (mIGF-1), a major mediator of muscle stem cell growth and differentiation. As a consequence of IGF-induced stimulation, muscle stem (satellite) cells multiply, differentiate, and fuse. As a result, the number of muscle fibers increases.

Biotechnological research and development have introduced new possibilities for producing similar muscle proliferation and enhancement, both genetic and pharmacological. The genes for animal and human IGF-1 have been cloned and their DNA sequences determined. Gene expression vectors have been developed that permit the regulated production of IGF-1 proteins (both the liver and muscle forms) for investigation. Thus IGF-1 genes can be introduced into cells and experimental animals-for example, by means of viral vectors-to determine the effect of enhanced IGF-1 (or mIGF-1) production on muscle size and strength. Recent experiments along these lines in animals have yielded very exciting results.

For example, in experiments described by Barton-Davis and coworkers,⁴ recombinant viruses^viii containing a rat IGF-1 gene were injected into the anterior compartment of the rear legs of young mice containing the extensor digitorum longus (EDL) muscle. The resulting increased production of IGF-1 promoted an average increase of about 15 percent in EDL muscle mass and strength in young adult mice. Strikingly, such injections led to a 27 percent increase in the strength of the EDL muscles when the mice approached the average lifespan of 27 months. In fact, the continued presence of additional (rat) IGF-1 genes essentially prevented the decline in muscle size and strength observed in untreated old mice.^ix ^x

An alternate route to genetic enhancement exploits the ability, at embryonic stages of development, to create transgenic animals in which an appropriately regulated foreign gene is expressed throughout embryonic and adult life. Musaro and his colleagues⁵ introduced a rat mIGF-1 gene into early-stage mouse embryos, where it became integrated with mouse chromosomal DNA. The resulting transgenic mice produced substantial amounts of rat mIGF-1, in addition to their own mouse IGF-1 and mIGF-1. Embryonic development of these transgenic mice proceeded normally. Yet as early as ten days after birth, the skeletal muscles of the transgenic animals were enlarged, compared to the non-transgenic control mice. Moreover, the skeletal muscle enlargement persisted as the transgenic mice aged. Whereas, in unmodified (wild type) mice, muscle size and strength peaked around six months and decreased considerably by twenty months of age, the size and strength of skeletal muscle in the transgenic mice (containing rat mIGF-1) remained stable at peak levels for up to twenty months.^xi

These and other experimental results stimulate thoughts about possible extensions of these approaches to humans. They hold out the promise of treatments for various diseases of muscle tissue, for sarcopenia and the weaknesses of old age, and for generalized enhancement of muscle strength and fitness in people of all ages, diseased or not. Based on our current understanding, at least three different approaches could be considered. First, one could introduce muscle-enhancing genes directly into the muscles themselves. To do so, one would need to develop recombinant virus vectors containing the human mIGF-1 gene, under the control of appropriate regulatory elements that would limit its expression to muscle cells near the site of injection. Alternatively, one might introduce an appropriately regulated mIGF-1 gene into human embryos, as was done in the experiments with mice. Finally, one might use an approach that combined techniques of stem cell and genetic engineering. After isolating and expanding human muscle stem (satellite) cells in vitro, one could introduce an appropriately regulated human mIGF-1 gene into those cells and then transplant the genetically modified satellite cells back into the muscles of the person being treated.

None of these three approaches has yet been tried in human beings. Each has its advantages and disadvantages.^xii Developing any one of them would take a lot of time and money, and many technical and logistical problems would need to be overcome before any treatment could be applied on a large scale. Even before the first genetic treatments to increase muscle size and strength could be tried in humans in the United States, the Food and Drug Administration (FDA) would require demonstrations that the proposed treatment is safe and effective.

Nevertheless, the time may be coming soon for human trials using the first approach, undertaken not to bulk up aspiring athletes but to treat human muscle diseases. Clinical trials of regulated mIGF-1 gene delivery as a treatment for specific forms of muscular dystrophy may begin within the next several years.⁶ These clinical trials will likely provide crucial data, en route, on administration, optimal dose, and possible side effects. If efficacy is demonstrated and side effects are small, one can easily imagine the social and economic factors that will favor vast expansions in the use of genetic muscle treatments to enhance muscle size and strength. High school wrestling and football coaches, having learned of the enhancing gene transfer experiments in rats and mice, have already expressed interest in obtaining such treatments for their athletes. Developing a product for which the eventual potential market is up to 100 percent of the human population will be hard to resist.

Genetic treatments for increasing muscle size and strength are still in the future. But pharmacological means of doing so are already here and in use, and both the desire and the rationale for their use is clear. As noted earlier, various hormones and growth factors play key roles in stimulating muscle stem cells to multiply, differentiate into myoblasts, and then fuse with existing muscle fibers. Growth hormone levels influence the size and strength of muscles, perhaps through the intermediacy of IGF-1. Testosterone levels influence muscle size and strength, helping to explain why men's muscles are generally larger and stronger than women's. Finally, local growth factors like mIGF-1 have important effects as well.

At the present time, three different sorts of drugs are being used to increase (or try to increase) muscle strength. In the newest practice, still on a very small scale, people have begun to use human growth hormone in attempts to enhance muscle size and strength, especially in the elderly. Now that the patent on human growth hormone has expired (2002), the cost of the monthly hormone injections is likely to drop from its steep $1,000. If this occurs, the scale of growth hormone use might very likely increase, as promotion for new uses grows; over the past year, unsolicited e-mail advertisements for human growth hormone have come frequently to the e-mail boxes of Council staff.^xiii Competitive athletes (and others) interested in boosting muscle size and performance have started using growth hormone-though the data suggest that its effectiveness is uncertain.⁷

A second approach to the enhancement of muscle performance works indirectly, not by enlarging muscle size but by increasing muscle endurance. Known as blood doping, it was originally accomplished by drawing blood from athletes, separating and concentrating the red blood cells, and then re-infusing the red blood cells into the athletes' bloodstream. This raised the amount of hemoglobin (the oxygen-binding protein) in the blood, and thus increased the oxygen-carrying capacity of the blood. Much the same effect can now be obtained by injections of the synthetic protein hormone erythropoietin, which stimulates the body to increase its production of red blood cells. For competitive cyclists, swimmers, and long-distance runners, increased oxygen-carrying capacity in the blood makes possible increased endurance, which in turn improves competitive performance.

The most commonly used chemical means of muscle enhancement are the anabolic steroids, chemical compounds related to hormones like testosterone. Taken orally (for example, "Anadrol" [oxymetholone], "Winstrol" [stanozolol], or "THG" [tetrahydrogestrinone]), or by injection (for example, "Durabolin" [nandrolone] or "Equipoise" [boldenone]), these drugs facilitate bodybuilding. Used in combination with weight training and special diets, they can greatly increase muscle size and strength. It is true that the precise benefits of these drugs for athletic performance are in dispute among scientific researchers, and, for obvious reasons, we have not seen adequate controlled studies to clarify their true effects. Nevertheless, many athletes, trusting their own experience and the testimony of teammates, are not waiting for the scientific evidence. Despite the known health risks and despite official opposition from the professional and college athletic authorities, as information about their effects has diffused throughout American society, more and more professional and amateur athletes are apparently using them. Also believing that they are effective-and that they are dangerous to the athletes-anti-doping sport organizations have banned most of them. At the same time, many (including the ones listed above) are listed as available for sale on the Internet.

Despite the opposition of Olympic and other sports officials to their use, the public attitude toward steroid use by athletes may be changing, at least for sports like baseball, basketball, and football. The recent outcry regarding Sammy Sosa's corked bat seemed to exceed any protests against the multiple revelations of steroid use by professional athletes. Malcolm Gladwell suggests an explanation:

It is hard to predict how widely genetic and chemical agents of muscle enhancement would be used, especially should safer versions be developed. Given the popularity of bodybuilding and fitness today, one could imagine that biotechnical agents would be useful for enhancing these activities, both in competitive and non-competitive settings. The commercial and competitive pressuresto use genetic muscle treatments to build up, maintain, and repair the muscles of competitive professional athletes in all sports would surely be very strong. And since athletic competition extends down from professional and collegiate ranks to youth soccer and Little League, there would seem to be no place to draw a line against using (safe) genetic or chemical muscle treatments. The incentive to use these treatments during adolescence or young adulthood might increase considerably if it should turn out that treatment during these earlier times of life is also the best means of protecting against the sarcopenia of old age.

Thus, it is not too farfetched to imagine that parents may one day be faced with difficult decisions regarding the development of their children's bodily capacities for athletics. What will and should they do when daughter Jenny's soccer coach tells them she would be a stronger player if they got her genetic muscle treatments, or that she is more likely to make the team if she gets treated? Would untreated children or aspiring athletes become significantly disadvantaged in a society in which many others had genetic or chemical muscle treatments? Conversely, would these new technologies at last provide the remedy for those to whom nature dealt a weaker bodily constitution? Given the difficulty of setting principled limits between the therapeutic uses of these new biotechnical powers and the uses that go "beyond therapy," why might we still seek to set any limits at all?^xiv What is it that such limits would or should seek to defend? It is none too soon to begin to think about these questions, for the future that will make them anything but speculative is now visible on the horizon.

IV. ETHICAL ANALYSIS

To begin the ethical analysis, we must try to distinguish between different ways of achieving superior performance, and how these ways of becoming better might alter, enhance, corrupt, or perfect our different activities. For those performance enhancements that we embrace, are we so sure that they are improvements, if we understand "improvement" to mean enhancing performance in ways that serve, rather than call into question, the dignity or excellence of human activity? And for those performance enhancements that trouble us, what is the nature of our disquiet? Because we want to see the bigger picture, we deliberately take a general approach to these questions, not tying our analysis to any specific means of boosting muscle strength and athletic performance. Rather than spend time on issues peculiar to a particular technique-say, the special safety concerns of genetic transfer, as contrasted with those associated with growth hormone or steroid use-we will concentrate on the larger issues raised by our acquiring and using the new bodily powers that these techniques, each in its own way, supply or promote.

The first task is to try to figure out whether using biotechnological means to gain superior performance is different from using better equipment or engaging in better training. If it is, what might the differences be, and what ethical and social difference do they make? This task is more difficult than it might at first glance seem, for there are similarities as well as differences among these three approaches. Some analysts will try to use such similarities to dismiss expressions of concern regarding drug-mediated improvements: "How are steroids really different from Air Jordan basketball shoes? Special diets and drugs both increase the capacity to train, so why make such a fuss about the drugs?" In response, it is worth emphasizing in advance that the ethical evaluation of biotechnological enhancements does not finally depend on their being found utterly unique and unprecedented. The fact that taking anabolic steroids or using genetic muscle enhancers could resemble, in some respects, using special diets or special bodybuilding programs does not by itself dissolve all our moral concerns. On the contrary, it might lead us to think more deeply about the more familiar modes of seeking to promote superior performance. Moreover, as we shall see, a careful examination may reveal that, similarities notwithstanding, the differences are in fact humanly and ethically significant.

In many areas of life, including sports, we take for granted that better equipment makes for better performance. Better gadgets, tools, machines, and devices are both yesterday's news and tomorrow's headlines. We habitually think and act in ways that assume the existence of such equipment, and in many areas of life, we work endlessly and deliberately to make cutting-edge improvements in our "high-performance gear." Unlike training or drugs that change the agent directly, the equipment that boosts our performance does so indirectly, yet it does so quite openly and in plain sight. We can see how the springier running shoes, the lighter tennis racket, and the bigger baseball glove enable their users to go faster, hit harder, and reach the formerly unreachable-yet without apparently changing them in their persons or native powers.

Yet appearances are deceiving. That their effects on our performance are indirect does not mean that they are trivial. And that they remain but visible tools in our hands does not mean that we remain in fact unaltered. Although the alterations, unlike the tools that produce them, are often hard to see, they often go very deep. Not only do we think and act in ways that assume enhanced equipment, we come to take its use for granted. Not only do we come to rely on our better tools; after a while, we have trouble remembering that we could do without them, largely because in truth we cannot do without them. This is not to suggest that we should do without them or that there is something wrong with accepting the extra edge that they give us in our pursuit of excellence. It is merely to insist that the use of equipment in sports, as in the rest of life, changes and even binds the human users, often without their knowing it.

The point was beautifully made by Rousseau, commenting on how even the earliest human inventors of artful aids to better living "imposed a yoke on themselves without thinking about it":

Our gear (like all our technology) not only improves the way we do things. In the process, it also often changes the very things that we do. It changes the abilities that matter most, and thus the character of our aspirations and the economy of social rewards. Once again, this is not to suggest we should not seek further improvements in our equipment. It is merely to recognize the far-reaching changes, in us and our activities, that the "merely" external equipment can cause-in all that we do, not only in sports. Because of graphite tennis rackets, tennis today is a game of faster serves, stronger strokes, and shorter points, and in consequence requires players of different talents and demeanor than it did only decades ago. Similarly, because of precision-guided weapons and drones, warfare now requires a different and more technical kind of expertise, often less demanding of, and less rewarding to, the physical human powers that served best in hand-to-hand combat. And because of computers, there is a premium on those with habits of mind shaped for programming; indeed, the very way many people think, speak, and write has changed to fit with the possibilities and necessities of the computer age. Adapting Winston Churchill's sage remark about architecture, we might say that we shape our equipment and our equipment shapes us.^xv

The distinction between better equipment and better training, and even between better equipment and better native powers, is for additional reasons not as sharp as one might wish. For some forms of athletic (and other) equipment are developed not to enhance specific performance as such, but rather to help individuals change or improve themselves precisely through better practice or training. For example, state-of-the-art weight training equipment aims at allowing individuals to make themselves stronger weightlifters and linebackers; state-of-the-art flight simulators allow individuals to make themselves better pilots. Such equipment is a tool that explicitly enables us to change ourselves through our own activity; it is an indirect means to directed and chosen change. Moreover-and more profoundly-the line between person and equipment may be eroding: we already have such therapeutic interventions as artificial limbs and mechanical implants to help blind people to see and deaf people to hear. Mechanical implants of various other kinds are no longer matters merely for science fiction.

Nevertheless, as with night and day in relation to twilight, the blurring of the boundaries between the several approaches does not make the territories themselves indistinct. We can still separate in our mind those means of altering or improving performance that work by giving us tools to perform in new ways, and those interventions that work by changing us directly-whether through self-directed activity and training or through direct biological interventions in the human body and mind. We can distinguish using better sneakers from daily running practice for an upcoming race, and both of these from running the race with the benefit of EPO or steroids. In addition, even though our tools change us, they do not necessarily change us irreversibly. We can, if we wish, still try to play baseball with the small, soft gloves of yesteryear, or softball with no gloves at all. Despite the fuzziness at the boundary, it still makes sense to distinguish our tools and equipment from our practice or training, as well as from the more direct biotechnical interventions aimed at improving our native bodily capacities.

In athletics, as in so many other areas of human life, practice and training are the most important means for improving performance, and superior performance is most generally attained through better training: the direct improvement of the specific powers and abilities of the human agent at-work-in-the-world, by means of his self-conscious or self-directed effort, exercise, and activity. To train is to be at work: striving, seeking, pushing, laboring, and developing. It requires self-knowledge or external guidance about the ends worth seeking, and it requires the desire and discipline to pursue those ends through one's own effort. And, most importantly for our purposes, training means acquiring by practice and effort improvements in the very powers and abilities that training uses. One gets to run faster by running; one builds up endurance by enduring; one increases one's strength by using it on ever-increasing burdens. The capacity to be improved is improved by using it; the deed to be perfected is perfected by doing it.

This insight has some important implications. First, it calls our attention to the very real differences in our natural endowments. If improving through training proceeds as described, certain native abilities are often a prerequisite. In many cases, no amount of training can overcome the unchangeable shortcomings of natural gifts. Second, and more important for present purposes, the source of our different endowments may be mysterious, but our active cultivation of those endowments, whether great or small, is intelligible: we can understand the connection between effort and improvement, between activity and experience, between work and result.

This leads to an important difference between improvements made through training and improvements gained through bioengineering. When and if we use our mastery of biology and biotechnology to alter our native endowments-whether to make the best even better or the below- average more equal-we paradoxically make improvements to our performance less intelligible, in the sense of being less connected to our own self-conscious activity and exertion. The improvements we might once have made through training alone, we now make only with the assistance of artfully inserted IGF-1 genes or anabolic steroids. Though we might be using rational and scientific means to remedy the mysterious inequality or unchosen limits of our native gifts, we would in fact make the individual's agency less humanly or experientially intelligible to himself.

The IGF-1-using or steroid-using athlete surely improves: he (or she) develops and becomes superior-and certainly the scientist who produced the biological agents of such improvement can understand in scientific terms the genetic workings or physiochemical processes that make it possible. But from the athlete's perspective, he improves as if by "magic," without the self-conscious or self-directed activity that lies at the heart of better training. True, steroids (or, someday, genetic muscle enhancement) will enable him to perform at a higher level only if he continues to train. True, as he trains, he still tires, perspires, and feels his (altered) body at-work. But as the athlete himself can surely attest, the changes in his body are decisively (albeit not solely) owed to the pills he has popped or the shots he has taken, interventions whose relation to the changes he undergoes are utterly opaque to his direct human experience. He has the advantage of the mastery of modern biology, but he risks a partial alienation from his own doings, as his identity increasingly takes shape at the "molecular" rather than the experiential level. Indeed, the athlete's likely embarrassment proves the point: Even were steroids or stimulants to become legal, one imagines that most athletes would rather not be seen taking their injections right before the race. For there is something shameful about revealing one's own chemical dependence right before demonstrating what is supposed to be one's own personal excellence.

This is not to suggest that changes in the body produced through training and effort are not also molecular, or to ignore the fact that the very purpose of certain biochemical interventions (such as anabolic steroids) is to increase the individual's capacity to train. In expressing this uneasiness about biotechnical enhancement, we are not celebrating some fictitious agency divorced from bodily events and consequences: whenever the body works or is at work, the body's underlying biology changes. Neither are we casting doubts on efforts to improve the body by means that work on it directly; to do so would require us to cast doubts on all of medicine and surgery, not to mention a well-ordered diet. Yet on the plane of human experience and understanding, there is a difference between changes in our bodies that proceed through self-direction and those that do not, and between changes that result from our putting our bodies to work and those that result from having our bodies "worked on" by others or altered directly. This is a real difference, one whose importance for the ethical analysis, as we shall see later, may prove decisive.

Yet in trying to preserve the distinction between intelligible agency and unintelligible agency-between getting better because of "what we do" and getting better because of "what is done to us"-we face a dilemma. Many of the basic activities of life-for example, eating, breathing, and sleeping-transform our bodies without our directing the actual work of transformation. Eating the right foods makes our system work better. Science can come to understand why this is so-why protein is "good" and fats are "bad," or how our bodies break them down and to what effect. But these processes of the body, however well understood, can never be made experientially intelligible in the same way our self-directed activities are intelligible. We digest and we dance, but digesting and dancing are very differently our doings.

We can control the food we eat, but improving our native digestion through practice is beyond our power. We dance by choice, both immediately and self-consciously, with the movements of the body connected to our active desire to dance and our self-awareness of dancing. Over time we can see our dancing improve, at least within the limits of our native capacities, and we can see that it is through our own practice that the superior performance has occurred. Clearly, as with eating, what happens in our bodies as we become better dancers is invisible and mysterious at the organic and molecular levels; it is intelligible, if at all, only in the terms of science, not of human experience. But the lived experience of dancing-of doing the deeds that enable us to do them again and do them better-matters a great deal. When we dance, our improvements are "our own," made possible by and limited by our native biology, but still the result of our own self-directed activity.

And here we begin to understand the complexity: To be a human organism, possessed of a body all of whose activities are mediated by invisible and molecular events, means that our identity is always to some degree independent of all our self-conscious efforts to mold or control it. In important ways, our bodily identity and our bodily capacities are inborn, inherited, and "given," and much of what our bodies do thereafter is shaped by processes and in ways we do not direct or fully grasp at the level of inner human experience. We cannot make our bodies into just anything we like, no matter how hard we try. As human individuals, we are not simply the beings or persons that we will ourselves to be, precisely because we are biological beings-with finite capacities and a finite body, which make having an identity possible in the first place. And yet, if there are limits to what we can do, there are also possibilities. We can actively change our bodies and change ourselves in important ways, precisely by trying, doing, working, and performing the very activities we seek to do better.

Even in the most self-directed activities, we remain ignorant, on the level of experience, of what is transpiring chemically in our bodies. This fact has an important implication: The difference between improving the body through training and improving it through diet or drugs is not absolute but a matter of degree. Nevertheless, the fact that the difference is one merely of degree does not make it humanly insignificant. Some acts are more, and some acts are less "our own" as human and as individuals. When we seek superior performance through better training, the way our body works and our experience and understanding of our own body at work are more closely aligned. With interventions that bypass human experience to work their biological "magic" directly-from better nutrition to steroids to genetic muscle enhancements-our silent bodily workings and our conscious agency are more alienated from one another.

The central question becomes: Which biomedical interventions for the sake of superior performance are consistent with (even favorable to) our full flourishing as human beings, including our flourishing as active, self-aware, self-directed agents? And, conversely, when is the alienation of biological process from active experience dehumanizing, compromising the lived humanity of our efforts and thus making our superior performance in some way false-not simply our own, not fully human? Better nutrition seems an obvious good, a way of improving our bodily functioning that serves human flourishing without compromising the "personal" nature or individual agency of what we do with our healthy, well-nourished bodies. But moving outward from there, the puzzle gets more complicated. Where in the progression of possible biological interventions do we lose in our humanity or identity more than we gain in our "performance"? Is there a way to distinguish coffee and caffeine pills to keep us awake from Modafinil to enable us to avoid sleep entirely for several days, from amphetamines to keep us more alert and focused, from human growth hormone, steroids, and EPO to improve strength and endurance, from genetic modifications that make such biological interventions more direct and more lasting? All of them alter our bodily workings; all of them to varying degrees separate self-directed experience from underlying biology.

Does that mean that we are incapable of distinguishing among them, humanly and ethically? Can our disquiet about pharmacological and genetic enhancement withstand rational scrutiny? More deeply, what does the prospect of such interventions tell us about the nature of human activity and the meaning of human identity? These are perhaps the deepest questions for the ethical analysis that follows. But to see why this is so, we must first consider some more familiar sources of ethical disquiet.

The most obvious disquiet with performance-enhancing agents in athletics, both equipment like corked bats and biological interventions like steroids, stimulants, or future genetic muscle boosters, concerns fairness: the worry that players using them will have an unfair advantage over other players, the concern that injustice will be perpetrated against one's rivals. Games have rules, and breaking the rules in these ways undermines the fairness of competition and the dignity of the game. This is, of course, a proper concern. But the question of fairness is more complicated than it looks at first.

Athletics, like many other human activities, depend on native gifts that are unequally distributed. Indeed, human sport often highlights and celebrates the very real differences and inequalities in our biological "starting points." In most sports, we do not, in the name of equality, require that our athletes (or others) with special talents assume handicaps so that everyone might compete on an equal footing.^xvi Although we may never settle the ancient and complicated question about how much of our various achievements is due to "nature" and how much to "nurture," there is no question but that gifts of nature have much to do with all sorts of human excellence. Many individuals, lacking certain physical and mental attributes (for example, height, muscle potential, eye-hand coordination), will never achieve the highest levels of human performance in certain activities no matter how hard they strive. At the same time, nature is hardly the whole story. Many individuals, with more limited native powers, will outperform those who are less willing or less able to cultivate their superior gifts.

Some have argued that allowing performance-enhancing drugs would be an acceptable-or even desirable-means of leveling a playing field that is unequal by nature. It could make athletic competition more perfectly fair, allowing winners to become those who do the best rather than those who are the best. But others argue that such drugs would only exacerbate the naturally unequal endowments rather than correct them. For even were there to be an "enhancement commissar" who calculated what degree of "boost" each person needed in order to get even with the natively gifted, there would be no way to titrate all the relevant gifts.^xvii Besides, in a free country there would be no basis for denying the same performance-enhancers also to the more talented. Why, if they wish it, should those destined to be tall or bulky be refused a chance to become taller or bulkier through growth hormone? As a result, those who are "best by nature" would become even better by augmenting nature's gifts with biological enhancements. And whether we allow or disallow such enhancements, we are not likely to alter the inherent biological inequalities that are part of being human, and that are important for human excellence in sports and many other activities. Fairness is always limited, to some degree, by the mysterious gifts of nature, even if such gifts are not solely responsible or even decisive for who will in the end become excellent or who will perform excellently.

The inequality of natural endowments highlights a related dilemma regarding the standards of excellence: to what extent should we judge performances superior for being "the best they can be," rather than simply being the "best"? For example, we celebrate both the real Olympics, which measures the best of the best, and the Special Olympics, which measures the best of those who strive in spite of great natural disadvantages. In the real Olympics, we honor the best human runner, and we appreciate the fact that the excellence of human running is not relative; it can be truthfully and quantitatively measured. At the same time, we judge the Special Olympians according to a different standard. We regard their activity as a kind of excellence-of personal achievement rather than of absolutely superior performance-even as they compete in the same activity with much lower scores. Standards of excellence also change with the times. In some sports, the average professional athlete of today probably has better scores and more physical strength than the greatest champions of yesteryear. But which of these individuals-today's no-name or yesterday's giant-do we judge as "superior" or more excellent?

In sum, there seems to be an "absolute" dimension to human excellence: in certain activities, there is such a thing as the best human performance. And yet, judging human excellence also depends on making sense of nature's unequal allotment of gifts, as well as the way particular human activities, for various reasons, change over time. We need to fit our scales of excellence to the thing being weighed, resisting the twin errors of believing that all excellence is relative or that all excellence can simply be ranked and determined by "score."

Still, there is a danger of sentimentality, as well as of confused thinking, in admiring athletes largely for the excellence of extra effort. The perfectly fitting praise of the resolve, effort, and devotion necessary to perform in the face of serious handicap is praise more for human will and determination, less for superior performance as such. As we shall emphasize below, human performance humanly done does involve human intention, choice, and will; yet it would be strange to celebrate mainly human willfulness in activities such as athletics that display, above all, bodily grace and beauty. This observation suggests that, in athletics, it is the harmonious and seemingly seamless fusion of mind and body that is crucial to the athletic ideal of superior performance. Neither the human body regarded as mere animal, nor the human body regarded as recalcitrant slave to be whipped into shape by an unbending will, but the human being displaying in visibly beautiful action the workings of heart, mind, and body united as inseparably as the concave and the convex-that, as we shall argue shortly, is the heart of humanly superior performance.

Finally, at least in sports, fairness understood as "playing by the rules" is a matter of convention. When it comes to steroids, EPO, or corked baseball bats, the concern about unfair advantage is to a large degree self-created. It is only because these performance-enhancing agents are disallowed, and because those who use them must do so outside the rules and surreptitiously, that we regard their use as unfair. But if steroids were declared legal in competition, everybody (or nearly everybody) who desired to compete at the highest level in most sports might well use them. The problem of fairness of access and extra advantage would largely disappear-though the problem of natural inequality would remain. It is therefore not enough to defend the rules (no steroids, no corked bats) and decry those who break them. The rules themselves-why they exist and what they are defending-must be understood and supported. This must be done on grounds that go beyond equality and fairness toward others to the nature and meaning of the activity itself.

A second source of disquiet centers on issues of freedom and coercion, both overt and subtle. The pride most nations (and schools) take in their athletes is often far from benign, and there are well-known cases in which countries and coaches have forced athletes to use performance-enhancing drugs. In East Germany before the fall of communism, to take just a single example, the young members of the women's Olympic swim team took regular doses of the anabolic steroid known as Oral-Turinabol. This improved their strength and endurance, but it also caused terrible masculinizing side effects (severe acne, uncontrollable libido, gruff voices, abnormal hair growth). Those women who were brave enough to inquire about what they were taking were told that the drugs were simply "vitamin tablets." As one of the swimmers testified years later: "I was fifteen years old when the pills started. . . . The training motto at the pool was, 'You eat the pills, or you die.' It was forbidden to refuse."¹⁰

But the potential for coercion-or at least intense social pressure-is certainly not limited to tyrannical regimes and despotic coaches. Should the use of an enhancing agent become normal and widespread, anyone who wished to excel in a given activity, from athletics to academics, might "need" to use the same (or better) performance-enhancements in order to "keep up." Anecdotal evidence suggests that this "soft coercion" may already be a problem, given the widespread underground use of illegal substances in many professional sports. True, the individual users, in such circumstances, are still choosing the drugs for themselves. They are free in a way the East German swimmers were not. But their choice is constrained by the fact-or by the belief-that it would be impossible to compete, or compete on an equal playing field, without them. They see the alternative of not using them as a kind of "unilateral disarmament," virtually guaranteeing that only those individuals with every biological advantage would excel or succeed. In professional sports, where not only victory but big money is at stake, the pressures not to disarm oneself pharmacologically will be-are already-enormous.

The point can be generalized beyond athletics, and when this is done, we see additional reasons for concern. In a meritocratic and results-oriented society such as ours, the vast numbers of people caught up in the race "to get ahead" come to feel increasing pressures to enhance their performance. Most are probably moved less by the desire for excellence, more by the love of gain or the wish to beat out the next fellow. As mounting social and economic competition keeps ratcheting up the pressures, people look for any advantage that might win them the more lucrative or higher-status job or that would increase their children's chances of gaining admission to the more prestigious schools. Under these social conditions, with spiraling love of gain conjoined with rising demand for recognition, the temptation in all walks of life to use biotechnologies for some "extra edge" probably rises with the pressure to compete. Today, professional athletes-and those who dream of becoming professional athletes-often succumb to the temptation. Tomorrow, the same might be true in many other areas of human endeavor.

Yet these quite legitimate concerns about pressure and constraint must be examined more closely. For the fact is that athletic (and other) competition is, in important ways, constraining or pressure-filled by nature. By becoming better, our opponents force us to match their improvements or fall behind and fail. By the entirely accepted (and generally laudable) means of training, dieting, or superior coaching, they challenge us to meet or better their improvements. Moreover, the quest for excellence, even in activities (like music or ballet) that are not in essence competitive, typically comes with stiff demands, and anyone who is serious about superior performance has little choice but to yield to or embrace them. The question therefore becomes: Which demands and "necessities" of the pursuit of superior performance are defensible and which are not? Which serve human excellence and which compromise or undermine it?

Seen most clearly, the concern about coercion, as with equality and fairness, turns out to be a pointer to other and deeper concerns, concerns about what gives an individual performer his or her dignity, and what makes an individual performance humanly excellent. If there is a core difficulty here, it is with the biological enhancers themselves, not with the fact that individuals might feel constrained or compelled to use them.

One of the central concerns about the biotechnical agents themselves is the risk and reality of adverse and undesirable "side effects," in the first instance, on bodily health and safety. The unintended cost of seeking stronger muscles and superior performance through drugs or genetic engineering could well be bodily (or mental) harm. With drugs like steroids, the grave long-term health risks are well known: they include, among others, liver tumors, fluid retention, high blood pressure, infertility, premature cessation of growth in adolescents, and psychological effects from excessive mood swings to drug dependence. With looming biotechnical powers like genetic muscle enhancement, the side effects are for now uncertain. But until proven otherwise, it makes sense to follow this prudent maxim: No biological agent powerful enough to achieve major changes in body or mind is likely to be entirely safe or without side effects. Moreover, targeted interventions aimed at enhancing normally functioning capacities, not repairing broken parts, could produce lopsided "improvements" that throw whole systems out of kilter: monster muscles could threaten unenhanced bones and ligaments.

The concern about safety is a real one: to be an athlete should not mean accepting a sentence of premature death or serious disease or disability, later if not sooner. As admirers of athletes, we should not want to exploit those we most esteem; we should not want to use them up for our own entertainment and satisfaction; and we should not want to treat our fellow human beings as expendable animals. But the concern about safety must also be subjected to scrutiny. Athletic activity is often intrinsically unsafe: Boxing and football, hockey and skiing-such activities require daring, toughness, and sometimes even contempt for "mere safety" as being far less important than victory and achievement. Superior performances in these activities would be less excellent or less genuine if fully stripped of their perils. Inasmuch as risk and sacrifice are part of what it takes to be superior, one might even argue that an athlete's willingness to use such drugs, at so great a personal cost, is not dehumanizing but admirable-a sacrifice of oneself to the game one loves.

Of course, there seems to be a difference between the uncertain dangers of the playing field and the deliberately self-inflicted harm of using performance-enhancing drugs.Playing a game with the risk of great harm seems different from inflicting high-tech, premeditated, long-term damage on oneself to gain a short-term advantage. The hazards intrinsic to the game are generally unavoidable, while those associated with taking the drugs are utterly unnecessary. But again, we must wonder: Why should we value the long-term over the short-term-the long healthy life over the short and glorious one? Isn't part of our admiration for athletics precisely the "gladiator spirit,"including the willingness to forego "mere safety" for brief but memorablemoments on the field of glory? Absent further analysis, there would seem to be a potential nobility on the part of the athlete who seeks excellence at whateverpersonal cost. And yet, there also seems to be something perverse, or ignoble, in coming deliberately to abuse one's body for the sake, presumably, of showing off its beautiful and splendid gifts and activities. There seems to be something dehumanizing in coming to rely so heavily on one's chemist to excel, to the point where one might wonder whether such excellence is still "personal" at all.

Some enhancements, both here and coming, may become physically safe, with few side effects that compromise the long-term health of those who use them. Yet there are other consequences "to the side" that deserve our concern, for such enhancements might change the body or mind in ways beyond making them ill. For it stands to reason that drugs sufficiently capable of affecting us in ways we desire are likely to affect us in ways that we do not seek and cannot predict. Perhaps certain hormones that boost training capacity and aggressiveness will make the individual emotionally less "well-balanced" in everyday life. Or perhaps by taking drugs that increase tolerance for physical pain, the individual will decrease his or her experience of other physical pleasures. Part of the problem with certain biological enhancements, in other words, may be that they isolate one set of human powers-the powers that make for a superior runner, linebacker, or weight lifter-at the expense of other areas of life: health, to be sure, but also calmness, balance, equanimity, pleasure, creativity, and so forth. Such enhancements risk creating a distorted form of human excellence-magnifying certain elements of human life while shrinking others.

But the "distortions" of life in pursuit of superior performance cannot be blamed on biotechnical enhancers alone. In any society in which people feel driven by the desire for success, whether measured in terms of wealth, power, or status, many human activities (including athletics) are easily bent out of their natural shape in order to serve these external goals. Yet the difficulty exists even when superior performance is pursued not for outside ends but for its own sake. All human excellence, to some degree, requires at least some distortion: putting aside many activities or aspirations to excel in one; leaving several powers undeveloped to develop a few; sacrificing most human goods to pursue a single one at the highest level; and perhaps becoming so excellent in one particular area of human endeavor that most other human beings only encounter such superior performance at a distance. All excellence, in other words, requires at least some separation from the majority: the separation required by long hours of practice and the separation inherent in performing in the arena or on the stage. We need think only of the strange life lived by Olympic gymnasts, often whisked away from normal childhood at a very early age to enter the all-consuming world of the training camp. Or the women's Olympic volleyball teams that not only practice but live in camp together 365 days a year for nearly the entire four years between the quadrennial events. Sometimes this separation from others and from ordinary life enables individuals to embody the best that human beings are capable of, at least in a particular area of activity. At other times, the separation might be so severe, and the way we pursue our chosen activity so distorting of the human whole, that the dignity of the performer is called into question. He or she might be a great athlete, but only by becoming inhuman in other ways. Viewed more fully, the concern about side effects, beginning with health, gets us to the deepest matters and the greatest "side effect" of all: that we improve performance at the cost of our full humanity; that we become "better" by no longer fully being ourselves.

The preceding analysis has considered several sources of our disquiet about different technical and biotechnological agents that might enhance or alter athletic performance: unfairness and inequality, coercion and constraint, and adverse effects on the health and balance of human life. Each has indicated something important; but none gets us to the core issue. The problem is not simply inequality and unfairness, since our natural endowments are unequal to begin with, and the conventions outlawing certain enhancements could be changed to allow everyone equal access to the same technical and biotechnological advantages. The problem is not simply coercive pressure, since only if there is something intrinsically troubling about bioengineered enhancements should we be really troubled by the pressures to use them, especially given that "pressures" are inherent in the pursuit of athletic or any other kind of excellence. And the problem is not simply health hazards and adverse side effects, or the ways that enhancing certain human capacities might limit or endanger other elements of human life. For the pursuit of athletic (and other) excellences necessarily seeks something higher than mere safety, and excellence nearly always requires putting aside some aspirations to pursue others; the individual accepts less excellence in many aspects of life in order to be excellent in this one. Yet the concern about compromising the whole of life for the sake of one isolated part points us closer to the heart of the matter: understanding the true dignity of excellent human activity, and how some new ways of improving performance may distort or undermine it.

Our deepest concerns are tied to the large questions we raised at the start of this chapter: What is a human performance, and what is an excellent one? And what makes it excellent as a human performance? For it seems that some performance-enhancing agents, from stimulants to blood doping to genetic engineering of muscles, call into question the dignity of the performance of those who use them. The performance seems less real, less one's own, less worthy of our admiration. Not only do such enhancing agents distort or damage other dimensions of human life-for example, by causing early death or sexual impotence-they also seem to distort the athletic activity itself. It is not simply that our greatest sportsmen could become bad fathers if their enhancements made them uncontrollably aggressive or left them prematurely dead. It is that they are, despite their higher scores and faster times, bad or diminished as sportsmen-not simply because they cheated their opponents, but because they also cheated, undermined, or corrupted themselves and the very athletic activity in which they seem to excel.

What is at stake here is the very meaning of human agency, the meaning of being at-work in the world, being at-work as myself, and being at-work in a humanly excellent way. To clarify this claim, we must consider several aspects of human activity and human agency. Before doing so, we must first address the matter of competition and its significance for the things we do.

We have already noted, in the discussion of coercion and constraint, the distortions that social pressures to get ahead introduce into athletics and other human activities. Yet unlike many of our activities-such as learning, doctoring, or even governing-athletics are intrinsically competitive. They involve a contest of single opponents or opposing teams, matching their talents against one another and seeking on that day or in this event to be better than the rest (or better than the best). Sometimes competition is friendly, a playful meeting of fellows who take pleasure in each other's achievements. Sometimes competition is fierce, mixed with a desire not only to see oneself victorious but to see one's opponent roundly defeated. Most often, competition mixes the friendly and the fierce: good friends are often rivals on the playing field, and bitter opponents often have a deep respect for one another as being worthy foes, demanding and evincing one's own best efforts.

But not all human activity, as we have noted, is intrinsically competitive and rivalrous. Consider, as a comparison to human sport, the activity of making music. It is certainly the case that musicians sometimes compete with one another: for first chair in the orchestra, for record contracts, for prizes and public esteem. But strictly speaking, when engaged in these rivalries they are not at work making music. Indeed, it seems misguided to say that music is in its essence a competitive activity-in the way Olympic running and professional chess are intrinsically competitive activities. When the string quartet or the symphony orchestra makes music, it has no opponent against whom it is competing. Moreover, no musician's performance or excellence can be "measured" in the same way as the shot-putter's or the runner's when he or she breaks a world record. To be sure, we can judge some musical performances as clearly better than others, and individuals strive to become better musicians than they were before. But the many forms of musical excellence seem to belie final comparative judgments about better and worse: two individuals can play the same sonata or sing the same song very differently but both excellently, each capturing something essential but something different in the music. Runners in the same race may run differently-with different styles, each embodying a different form of excellent running-but in the end we can say, at least in a given race, who is the "best."

And yet, even those activities that are intrinsically competitive, such as sports, are not simply competitive in their essence. The dignity of athletic activity is not defined only by winners and losers, faster and slower times, old records and new. Competition can sometimes blind us to the fact that it is not simply the separable, measurable, and comparative result that makes a performance excellent-but who is performing and how. The word "superior" itself captures this dichotomy, meaning both "better than one's competitor" but also denoting a performance or activity that is simply outstanding in itself. Excellent running seems to have a meaning-the human body in action, the grace and rhythm of the moving human form, the striving and exertion of the aspiring human runner-that is separable from competition, even when the runner is running competitively. Even in the most competitive activities, the deepest meaning may not be honorable victory, or beating one's best human opponents in a worthy way, but rather the human agent at-work in the world-especially the lived experience, for both the spectator and doer, of a humanly cultivated gift, excellently-at-work.

This leads us to the second consideration: the relationship between the doer and the deed, or between the human agent and the human activities he or she engages in. As said above, the dignity of human sport (or any other human activity) is determined not simply or predominantly by the measured and separate result, but also by who achieves it and how. Seen not as a detachable deed but as an activity of an agent, athletic performance depends on both the doing of a deed and the identity of the doer. The purpose of competitive running, for example, is to cover the set distance as quickly as possible. But this is only part of the story. The man on roller skates moves more quickly than the runner. But he obviously engages in a different activity-moving quickly, but not running-and thus should be judged according to a different standard. (Just because we have invented roller skates, cars, and airplanes-all faster ways of moving-does not mean we have stopped competing in running.)

Animals run, often quickly. In contrast with mechanized movement, in animal running doer and deed are seamlessly united. And as already noted, the average cheetah runs much faster than the fastest human being and is beautiful to behold. But we do not honor the cheetah in the same way we honor the Olympic runner, because the Olympian runs in a human way as a human being. (Of this, more soon.) In a word, in athletic performance seen as a performance of a performer, we cannot separate the "result" (the fastest time) from the "activity" (human running). In assessing athletic performance, we do not in fact separate what is done from how it is done and who is doing it, from the fact that it is being done by a doer. And we should not separate the score from the purpose of keeping score in the first place: to honor and promote a given type of human excellence, whose meaning is in the doing, not simply in the scored result. Tomorrow's box score is at most a ghostly shadow of today's ballgame.

Consider another example: the best human chess player playing against a chess-playing computer. It is worth asking how or whether man and machine are really "competing" at all, and to what extent we can really compare the superior capacity of a computer to "play" chess with the distinctive excellence of a human chess player. On one level, of course, they are indeed competing: playing the same game according to the same rules. And yet, the computer "plays" the game rather differently-with no uncertainty, no nervousness, no sweaty palms, no active mind, and, most importantly, with no desire or aspiration and no hopes or expectations regarding possible future success. In this new type of competition, our best human being faces off against our best human artifact. But the computer's way of "playing" is really a kind of simulation-the product of genuine human achievement, to be sure, since building such a computer is its own manifestation of human excellence. But is this simulation the real thing-playing chess?^xvii And by building computers that "play" perfect chess, do we change the meaning of the activity itself? Do we reorient the very character of our aspiration-from becoming great human chess players to becoming better chess-playing machines, or, if you prefer, from becoming great chess players to producing the best-executed game of chess? Why, if chess is no more than the sum of opposing moves that are in principle calculable by a machine, would human beings wish to play chess at all, especially if the machines can do it better?

The answer is at once simple and complex: We still play chess because only we can play chess as human beings, as genuine chess players. We still run because running, while not as fast as moving on wheels, retains a dignity unique to itself and unique to those who engage in this activity. The runner on steroids or with genetically enhanced muscles is still, of course, a human being who runs. But the doer of the deed is, arguably, less obviously himself and less obviously human than his unaltered counterpart. He may be faster, but he may also be on the way to becoming "more cheetah" than man, or more like the horses we breed for the racetrack than a self-willing, self-directing, human agent. He does the deed (running), and his resulting time may be measurably superior. But he is also (or increasingly) the passive recipient of outside agents that are at least partly responsible for his achievements.

This brings us to a third and closely related consideration, the specific difference of a human act or performance. For in judging a performance to be genuinely and humanly superior, we care not only that there be an integral connection between doer and excellent deed. We care also that the doer-at-work display those qualities that make us admire the performance as a human activity and as his own activity. Borrowing a useful distinction from moral philosophy, not all acts done by humans are human acts, acts that spring from the roots of our humanity. Not all acts done by persons are personal acts.

One common way of getting at the crucial difference is to talk about "true" and "false" acts, acts that do and acts that do not spring truly from who or what we are. This is what people have in mind when they say that athletes who use steroids or a corked bat to hit the ball farther than they could before are not only breaking the rules, but getting their achievements "on the cheap," performing deeds that appear to be, but that are not in truth, wholly their own. This makes sense as far as it goes, but it gives rise to the question, "What would make an act of humans genuinely a human act?" "What would make the deed truly one's own?"

Comparison with the doings of animals other than man proves helpful. In the activity of other animals, there is necessarily a unity between doer and deed; acting impulsively and without reflection, an animal-unlike a human being-cannot deliberately feign activity or separate its acts from itself as their immediate source. Yet though a cheetah runs, it does not truly run a race. Though it senses and pursues its prey, it does not seek a goal with full consciousness or with ambitions to surpass previous performances. Though its motion is voluntary (not externally compelled), it does not run by choice. Though it moves in ordered sequence, it has not planned the course. Its beauty and its excellence-and these are not to be disparaged-it owes largely to nature and instinct.

In contrast, the human runner chooses to run a race and sets before himself (herself) his (her) goal. He measures the course and prepares himself precisely for it. He surveys his rivals and plots his strategy. Though constrained by the limits of his flesh, he cultivates and disciplines his body and its natural gifts in pursuit of his goal. The end, the means, and the manner are all matters of conscious awareness and deliberate choice, from start to finish. In a word, what makes the racer's running a human act humanly done is that it is done freely, knowingly, and by conscious choice.

So far so good. But if the humanity of our actions rests solely on their being rooted in knowledge and conscious choice, we face this difficulty: Is not a decision to enhance our bodies through drugs or genetic intervention also a matter of human choice? Why would this not be precisely the expression of our rational will, a manifestation of its peculiarly human ability not to be enslaved by the limitations of our animal bodies? If it is the presence of free, knowing, and conscious choice that makes for a human act, then the bulking up of the genetically or drug-enhanced athlete-and derivatively, his drug-assisted superior performance-would seem to be preeminently human or even superhuman, a manifestation of our ability to transcend nature's and our personal limitations in a way no animal can.

This welcome objection invites a fuller account, with a three-part response-one regarding the mind (and will), another regarding the body, the third regarding their peculiar interrelations as expressed in athletics and human activity more generally, as well as in human desire and aspiration.^xixThe point about the mind has already been prepared by our earlier discussion of the difference between gaining superior performance through training and practice and gaining superior performance through biotechnological intervention and engineering. We called attention to the difference between perfecting a capacity by using it knowingly and repetitively and perfecting a capacity by means that bear no relation to its use. And we stressed the difference, on the plane of human experience and understanding, between changes to our bodies that do and those that do not proceed through intelligible and self-directed action, capable of being informed by the knowledge of human experience. Thus, though the decision to take anabolic steroids to enhance athletic performance can be said to be, in one sense of the term, a rational choice, it is a choice to alter oneself by submitting oneself to means that are unintelligible to one's own self-understanding and entirely beyond one's control. In contrast with the choice to adopt a better training regimen, it is a calculating act of will to bypass one's own will and intelligibility altogether.

Yet the problem with biotechnical enhancement lies not merely on the side of exaggerated and self-contradictory willfulness. It lies also with its mistaken identification of the human with the merely rational and its neglect of our embodiment. For the humanity of athletic performance resides not only in the chosenness and intelligibility of the deed. It depends decisively on the performance of a well-tuned and well-working body. The body in question is a living body, not a mere machine; not just any animal body but a human one; not someone else's body but one's own. Each of us is personally embodied. Each of us lives with and because of certain bodily gifts that owe nothing to our rational will. Each of us not only has a body; each of us also is a body.

In few activities is this truth more manifest than in sports. When we see the outstanding athlete in action, we do not see-as we do in horse racing-a rational agent riding or whipping a separate animal body. What we mainly see is a body gracefully and harmoniously at work, but at work with discipline and focus, and tacitly obeying the rules and requirements of the game. We can tell immediately that the human runner is engaged in deliberate and goal-directed activity, that he is not running in flight moved by fear or in pursuit moved by hunger. Yet while the peculiarly human character of the running is at once obvious, the "mindedness" of the bodily activity is tacit and unobtrusive. So attuned is the body, and so harmonious is it with heart and mind, that-in the best instance-the whole activity of the athlete appears effortlessly to flow from a unified and undivided being.^xx

At such moments the athlete experiences and displays something like the unity of doer and deed one observes in other animals, but for humans that unity is a notable achievement which far transcends what mere animals are capable of. A great sprinter may run like a gazelle, a great boxer may fight like a tiger, but one would never mistake their harmony of body and soul for the brute instinct that spurs an animal toward flight or fight.

Athletic activity is not only generically human and manifestly a bodily matter; it is also emphatically the work of particular individuals. This is hardly accidental. Although we are all equally embodied, we are not bodily identical. On the contrary, our differing identities are advertised and displayed in our unique bodily appearance. True, in many gifts of body and mind we are indistinguishable from our fellow human beings; but in some gifts many of us are specially favored. It is the special distribution and assortment of common and particular gifts, allotted to each of us, that constitute the biological beginnings of our individual identity. In pursuing superior athletic (or other) performance, we are cultivating and exercising both our common and our particular gifts, seeking our own individual flourishing. We discipline our gifts through choice and effort in the service of enabling them to shine forth in our own beautiful and splendid activity. We take pleasure in our own performance and achievement. The added bonus of victory and the recognition that follows from it we esteem largely because they confirm that our own embodied excellence has been attained and that our desire for superior performance has been satisfied.

In trying to achieve better bodies through muscle-enhancing agents, pharmacological or genetic, we are not in fact honoring our bodies or cultivating our individual gifts. We are instead, whether we realize it or not, voting with our syringes to have a different body, with different native capacities and powers.^xxi We are giving ourselves new and foreign gifts, not nature's and not our own, and-exaggerating, but in the direction of the truth-treating ourselves rather as if we were batting machines to be perfected or as superior horses bred for the race and bound to do our bidding. These acts of will do not respect either our own individuality or the dignity of our own embodiment-on which, by the way, our will absolutely depends for its very existence.

At the root of all human activity is desire or aspiration, especially when it aims at excellence. Human aspiration for superior performance, for excellent activity, for something memorable and great, is not, finally, the product of pure reason or pure will. Neither is it merely the product of our animality. It stems rather from that peculiar blending of mind and desire, perhaps peculiar to human beings, called by the Greeks eros, the longing for wholeness, perfection, and something transcendent. In one formulation, it is the desire: (1) for the good, (2) to be one's own, (3) always.¹¹ The root of this longing lies in the awareness that, alas, we are not entirely unified and undivided beings. We are rather frail and finite in body and conflicted in soul. Being conscious of our finitude and self-division, we strive to make of ourselves something less imperfect, something more noble, something fine-something that would be fulfilling as much as is humanly possible. Further, we pursue this aspiration as ourselves and-at least to begin with-for ourselves. We would not seek excellence on condition that, in order to attain it, we would gladly have to become someone or something else.^xxii Not the excellence of god or beast, not even the excellence of some generic human person or disembodied human will, but the excellence of our own embodied allotment of human possibility is our goal. It is doubtful, to say the least, that biotechnical transformations of our bodies-or minds-will contribute to our realizing this goal for ourselves.

The ironies of biotechnological enhancement of athletic performance should now be painfully clear. First, by turning to biological agents to transform ourselves in the image we choose and will, we in fact compromise our choosing and willing identity itself, since we are choosing to become less than normally the source or the shapers of our own identity. We take a pill or insert a gene that makes us into something we desire, yet only by seeming to compromise the self-directed path toward its attainment. Second, by using these agents to transform our bodies for the sake of better bodily performance, we mock the very excellence of our own individual embodiment that superior performance is meant to display. Finally, by using these technological means to transcend the limits of our natures, we are deforming also the character of human desire and aspiration, settling for externally gauged achievements that are less and less the fruits of our own individual striving and cultivated finite gifts.

There is, we might add, no limit in principle to the desire to transcend the limits of our own nature. The desire to have a perfect body, one that perfectly executes the dictates of the will, is tantamount to a desire to transcend our embodiment altogether, to become as gods, to become something more-than-human. No doubt the longing for perfection has inspired many of the greatest human achievements. But unless guided by some idea of the character of human perfection, such longings risk becoming a full-scale revolt against our humanity altogether. Fueled in addition by a thirst not merely to excel but to defeat and surpass our rivals, the desire for superhuman powers easily becomes boundless.

The argument we have offered seems to have landed us in this strange position: We seek to defend human willing or agency, in the sense of defending our being what we really do. But we also seek to recognize the biological limits of the will, in the sense that much that is central about us is not truly our doing. Biotechnology seems to promise the triumph of the will with less willing effort and bodily excellence in bodies not quite ours: we can become what we desire without being the responsible and embodied agents of our own becoming. A more human course, however, might be accepting that we cannot will ourselves into anything we like, but we can still live with the dignity of being willing, self-directed, embodied, and aspiring persons, not biological artifacts, not thoroughbreds or pitching machines. Better, in other words, to be great human runners with permanent limitations than (non)human artifacts bred to break records.

Though our subject has not been athletics as such, but the uses of biotechnical means to enhance athletic performance, our analysis casts light on the ways in which the currently popular view of sports may already be corrupting genuine human excellence and may lead, unless we change our tastes, to enormous pressure to pursue any and all biological performance-enhancers, should they be safe and effective. For we have long since blurred the line between athletics and entertainment. If the baseball-loving public cares mainly about how many homers are hit or how far they go, then it will matter less how much the deeds flow from the unadulterated yet cultivated gifts of the hitter. Only if superiority of performance continues to mean not just the excellence of a detached act, but of the act as displaying the excellence of a superior human being, excellently at-work-in our own mindful and aspiring embodiments-can we preserve the full sense of humanly superior performance.

Much of the above analysis focuses on the excellence of the individual person at-work in the world. But any analysis of superior performance must also take into account the performer's relationship with others: teammates and competitors, teachers and admirers, co-workers and friends, as well as the larger community. It is true that the individual, even when working in tandem with his fellows, is excellent as himself. But excellent human activity is by nature situated within a community, a society, and a culture. The human individual flourishes as himself, but he does not flourish alone. And he rarely flourishes without enormous contributions from others, people near and even far to whom he is indebted for nurture, rearing, coaching, encouragement, employment, and the appreciation and support of the activity in which he gets the opportunity to excel. Likewise, all excellence is particular to time and place, even if particular examples of human excellence are "for all time," and even if we can admire those who perform in activities that we no longer engage in ourselves.

In myriad ways, society has a stake in excellent human activity. It rewards, honors, and nourishes the superior performances of its members. But it also expects, demands, and depends upon them. In many everyday functions-flying airplanes, fixing computers, educating children-we rely on others to "get the job done" or "rise to the occasion" when needed. We need them to perform and perform well, not just occasionally or sporadically, but steadily and reliably. Allowing some leeway to beginners, we expect practice will make perfect, we expect people to improve on the job and through the experience of repeated performance.

Beyond its everyday utility, superior performance also ennobles society: it makes everyone better; it raises the spirits of a community; it nourishes the desire to be better and to do better, as individuals and as a people. The example of superior performers gives those who are still developing an image of who or what they might aspire to become themselves. And everyone may be elevated by discovering that human beings-like them in being human, unlike them in the superior ways they perform-can do the beautiful and marvelous things they themselves cannot do, but in which they can surely, if only partially, participate as appreciators and admirers.

Our analysis of human sport sheds light also on the entire range of such socially valuable and excellent performances, both those that adorn our community and those that make it possible. Each of these human activities has its own character and meaning, and hence also its own dignity. In music, as in sport, the body is gracefully at work, but at work in a different way: the fingers striking the keys, the hand and arm moving the bow, the voice singing at perfect pitch. The musician takes inspiration from others-perhaps including rivals-but he does not compete. He makes music-arranging notes and melodies as a composer and playing them as a performer. But he also captures what is musical-hitting notes and singing harmonies as they were meant to be hit and be sung. He knows the notes and his body knows the movements. And guiding it all is his musical understanding of the musical whole, grasped in both heart and mind, that both inspires the performance and that is, when given life in the playing, its completion.

In a similar way, one might describe a range of other human activities-painting, dancing, building, designing, writing. Each of these activities has a distinct character and excellence, and each retains a dignity unique to itself, demanding and rewarding different human powers and capacities. But each of them, like sport, involves a humanly cultivated gift, a human doer and human deed, a deed performed, at its best, in a humanly excellent way. It is the human musician, not the synthesizing machine, whom we admire and defend: the musician with desire and fallibility, who creates what did not exist before and rises to the occasion when the moment most demands it. Most important, while such superior performances are the work of individuals, all of society shares in their excellence, as it always does when taste is receptive to genius. Properly appreciative witnessing is participating, and it enables everyone present to experience the surpassing human possibility in a passing human moment.

In addition, even those activities necessary for life in society and devoted to some external result or purpose-for example, human work to produce some useful object or to perform some needed service-can be done in a way that is dignified or undignified, human or dehumanizing. The difference is not simply how many objects are produced, with what efficiency and what effectiveness. What matters is that we produce the given result-the objects that we make-in a human way as human beings, not simply as inputs who produce outputs. Indeed, it is here that the temptation to improve performance-to make workers more focused by giving them Ritalin, less sleepy by giving them Modafinil, more muscular by genetically enhancing their muscles, and so on-is most tempting. If all that matters is getting more out of them-or more out of ourselves, by any means possible-then improving performance by every biotechnical intervention available makes perfect sense. But as we have seen with human sport, more is at stake than simply improving output. What matters is that we do our work and treat our fellow workers in ways that honor all of us as agents and makers, demanding our own best possible performance, to be sure, but our best performance as human beings, not animals or machines.

But there is one further complication. Defending what is humanly good or excellent must not only guard against the possibility of dehumanization; it must defend first against the many threats to personal or communal survival itself. When the very existence of the human agent or human society is at stake, certain special superior performances are not only edifying but urgent: for example, the superior performance of soldiers or doctors. What guidance, if any, does our analysis provide for such moments of extreme peril and consequence, in war or in medicine, when superior performance is a matter of life or death? Are some biotechnical interventions to enhance performance justified in these activities (surgery, war) while not justified in the other activities of human life (sports, music, test-taking)? In these circumstances, might we treat men as alterable artifacts-or willingly become artifacts ourselves-in order to "get the job done"?^xxiii

There may indeed be times when we must override certain limits or prohibitions that make sense in other contexts-offering steroids to improve the strength of soldiers while rejecting them for athletes, offering amphetamines to improve the alertness of fighter-pilots while rejecting them for students, offering anti-anxiety agents to steady the hands of surgeons while rejecting them for musicians. When we override our own boundaries, we do so or should do so for the sake of the whole, and only when the whole itself is at stake, when everything human and humanly dignified might be lost. And we should do so only uneasily, overriding boundaries rather than abandoning them, and respecting certain ultimate limits to ensure that men remain human even in moments of great crisis. For example: Even if they existed, and even in times of great peril, we might resist drugs that eliminate completely the fear or inhibition of our soldiers, turning them into "killing machines" (or "dying machines"), without trembling or remorse. Such biotechnical interventions might improve performance in a just cause, but only at the cost of making men no different from the weapons they employ.

This particular case, in short, is the exception that proves the rule: even in moments of great crisis, when superior performance is most necessary, we must never lose sight of the human agency that gives superior performance its dignity. We must live, or try to live, as true men and women, accepting our finite limits, cultivating our given gifts, and performing in ways that are humanly excellent. To do otherwise is to achieve our most desired results at the ultimate cost: getting what we seek or think we seek by no longer being ourselves.

We are well aware that this assessment of human activity and human dignity, highly philosophical, may not be persuasive to some people. And even those who might share the foregoing views of the possible corruptions of using direct biotechnical intervention to gain superior performance might be reluctant to argue against it for others. In a free country, so they might say, people should be allowed to take their muscle enhancers or alertness pills, even if we would not use them ourselves. Where's the harm if some football players here and there take steroids or a few ambitious college-bound students take stimulants before their SATs?

Perhaps none. Human life is complicated, innovations abound, and human activities often change their character without necessarily losing their integrity. But we must at least try to imagine what kind of society we might become if such biotechnical interventions were to become more significant in their effects and more widespread in their use. We might come to see human running and dog races, singers and synthesizers, craftsmen and robots, as little different from one another. Human beings, here mostly for our entertainment or our use, might become little more than props or prop-makers. We might lose sight of the difference between real and false excellence, and eventually not care. And in the process, the very ends we desire might become divorced from any idea of what is humanly superior, and therefore humanly worth seeking or admiring. We would become a society of spectators, and our activities a mere spectacle. Or a society of parasites, needing and taking, but never doing or acting. Worst of all, we would be in danger of turning our would-be heroes into slaves, persons who exist only to entertain us and meet our standards and whose freedom to pursue human excellence has been shackled by the need to perform-and conform-for our amusement and applause.

For a while-perhaps indefinitely-we might relish the superior results that only our biotechnical ingenuity made possible: broken records on the playing fields, more efficient workplaces, improved national SAT scores. But we would have gone very far, potentially, in losing sight of why excellence is worth seeking at all, and hence what excellence really is, and how we pursue it as human beings, not as artifacts.

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Footnotes

i. This chapter is, accordingly, about both the excellence and the humanity of "superior performance," and about whether improvements in performance do or do not compromise the humanity or individuality of the agent.

ii. Other areas where this is also true include music, dance, theater, and other performing arts.

iii. Similarly, the things that can corrupt, tarnish, or merely complicate sports-greed, vanity, the desire to injure or crush a rival-can corrupt, tarnish, or merely complicate most other human activities.

iv. We leave out of the account some further enhancements of "running," such as the use of wheels, or even motors, on the soles of shoes. Such changes, of course, would transform the activity into something other than running.

v.The age-related loss of muscle size and strength has been named "sarcopenia." (The term "sarcopenia" was first suggested by I. H. Rosenberg in 1989. It is derived from Greek words meaning "poverty of flesh." See Rosenberg, I., "Summary Comments," American Journal of Clinical Nutrition 50: 1231-1233, 1989.) We shall consider sarcopenia further in Chapter Four, "Ageless Bodies."

vi. The very idea of "muscle-bound" looks away from activity, and implies restricted freedom of motion; the hypertrophied muscles cut down somewhat the range of possible motion around some joints.

vii. Interestingly, female bodybuilders initially pursued the same path as the males. The result was women bodybuilding champions with smaller but similarly individually developed and articulated skeletal muscles. More recently there has been an aesthetic reaction against the resulting female muscle "overdevelopment" and, commercially at least, the more popular and profitable activity today is women's fitness competition.

viii. Recombinant viruses, engineered to express a specific foreign gene, are frequently used to stimulate the production of functionally effective amounts of the foreign protein to treat disease. Recombinant viruses created from genetically engineered human Adenovirus-associated Virus (AAV) have proved to be efficient delivery systems of foreign genes into muscle cells. As AAV is a small virus, only small foreign genes can be used effectively with this virus. Fortunately, the DNA sequence encoding IGF-1 is small enough to function well in AAV-based recombinant viruses.

ix Professor H. Lee Sweeney, the leader of the team conducting this research, gave a fuller description of his group's recent findings in his presentation to the Council in September 2002. According to Professor Sweeney, the insertion of IGF-1 genes into mouse muscles not only blocked the normal age-related decline of muscle size and strength; in addition, the researchers found, it caused the muscle tissue of older mice to retain the optimal power and speed normally found only in younger mice. It also improved the rate of repair of damaged muscle tissue. Other experiments on rats showed that, when IGF-1 gene injections were accompanied by strenuous exercise, not only did the rats develop bigger and stronger muscles, they also retained those enhanced muscles far longer than they normally would after the exercise had ceased. Should comparable results be attainable with human skeletal muscles, gene insertion would appear to hold great promise, both as therapy for muscular dystrophy and age-related sarcopenia and as a means to enhance athletic performance. See Sweeney, H., "Genetic Enhancement of Muscles," presentation at the September 2002 meeting of the President's Council on Bioethics, Washington, D.C. Transcript available on the Council's website, www.bioethics.gov.

x. (From previous page.) In this study, approximately 10¹⁰ recombinant AAV particles in 100 microliters of fluid were injected into a single small muscle compartment of mice. If such treatments were eventually to be applied to humans, large amounts of recombinant AAV containing the human IGF-1 DNA sequence would be required. Assuming such future treatments were shown to be safe and effective, producing sufficient recombinant AAV to treat millions of dystrophic and aging humans would remain a substantial logistical challenge. However, there may be ways around this logistical problem involving the production and transplantation of human muscle stem cells engineered to produce more IGF-1.

xi. The growing understanding of muscle physiology at the molecular level coupled with sophisticated genetic engineering has made it possible to enlarge skeletal muscles selectively, without damaging heart muscles in the process. In previous studies of this type, the IGF-1 transgene was not connected to gene expression regulatory elements that restricted production of mIGF-1 to muscle tissue. This led to overproduction of IGF-1 in the circulation, and eventually to pathological enlargement of the heart muscle. But in the studies with transgenic mice cited here, the rat mIGF-1 transgene was connected to gene expression regulatory elements that restricted production of the rat mIGF-1 protein only to muscle tissues containing primarily fast-twitch fibers. Side effects on the heart muscle did not occur.

xii. The first approach would be similar to other human gene therapy projects in children and adults. The appropriately regulated human mIGF-1 gene would be combined with a vector capable of efficient delivery to muscle cells, perhaps AAV. This material could be produced in large volumes, carefully characterized by tests in experimental animals, stored frozen and used as needed. While the logistics of producing the large amounts of recombinant AAV that would be required for treatment of thousands or millions of patients are daunting, in principle this would be possible. The advantages of this approach are (1) that it would develop and use a single, well-characterized biological agent; (2) that treatment could be started very slowly by introducing the recombinant mIGF-1 gene-containing AAV into one muscle at a time and evaluating its effects; (3) that treatment could be stopped immediately if untoward side effects developed. Disadvantages include (1) the possibility that a large number of injections would be necessary to treat each of the large number of human skeletal muscles; (2) the possibility that this would not be an effective treatment for humans who had antibodies to AAV as a consequence of a previous infection.

The second approach is a radical proposal, as it envisions treatment of blastocyst-stage human embryos in vitro with a genetic procedure that was intended to change the early development of skeletal muscle size and strength and reduce the rate of loss later in life. This approach shares some advantages with the first approach in that (1) a single biological agent could be prepared and characterized that could treat all embryos; (2) only a single treatment early in embryonic development would be needed, instead of multiple injections into different muscles. The major disadvantages of this approach are the difficult ethical questions it would raise, as well as the difficulty of meeting the safety criteria demanded of any germ-line or embryo genetic engineering (see Chapter Two, "Better Children").

The third approach depends upon the ability to isolate human muscle stem (satellite) cells and expand them in vitro. [This has recently been reported for mice. See Qu-Peterson, Z., et al., "Identification of a novel population of muscle stem cells in mice: potential for muscle regeneration," Journal of Cell Biology 157(5): 851-864, 2002.] The isolated human muscle stem cells would then have their mIGF-1 production genetically modified by introducing an appropriately regulated exogenous mIGF-1 gene copy. In theory, this could produce modified muscle stem cells that multiplied continuously in vitro to produce larger numbers of cells, and that differentiated appropriately in vitro. In this case, genetically modified satellite cells would be injected into skeletal muscles. The advantages of this approach include (1) it would develop and use a single, well-characterized biological agent to modify the muscle stem cells in vitro, and (2) the dose of modified stem cells could be varied as necessary to optimize treatment of individual skeletal muscles. The disadvantages include the possibility that a separate preparation of muscle stem cells would have to be made from each patient needing treatment, in order to get around the immune-rejection problem.

xiii. Earlier this year, the FDA enlarged the domain of approved uses for human growth hormone to include preventive treatment of short stature. To be eligible for approved use, a child's height must be more than 2.25 standard deviations below the mean for age and sex; that is, he or she must be among the shortest 1.2 percent of children. Obviously, successful treatment of this group would automatically create another group of children who were now the shortest 1.2 percent. Even before there was FDA approval, the uses of growth hormone were already expanding, with increasing acceptance of medical intervention for social gains. In an August 1996 article in the Journal of the American Medical Association, Leone Cuttler and colleagues report that six out of ten children receiving growth hormone are not actually growth-hormone deficient. Some of these children have other medical problems that stunt growth, but many receive treatment because their parents simply want their children to be taller. (Cuttler, L., et al., "Short stature and growth hormone therapy: a national study of physician recommendation patterns," Journal of the American Medical Association 276: 531-537, 1996.)

xiv. It has been suggested that along with the regular Olympics and the Special Olympics, we have the "Bio-Olympics," where the competition is unconstrained and the athletes are free to use any legal form of pharmaceutical or physiological enhancement.

xv. Better equipment is thought to be better because it does what old equipment did more effectively. But as it does so, the activities in which the old equipment was used are also altered, and not necessarily improved as a whole. We certainly have better tennis rackets-but is the game better now than it was then? We certainly have better weapons-but are the soldiers of today humanly superior to the soldiers of old, and is warfare today "better" than it used to be?

xvi. This bizarre prospect, the logical extension of a preoccupation with equality, is the ingenious conceit of a short story by Kurt Vonnegut, "Harrison Bergeron," in his collection, Welcome to the Monkey House. The goal is accomplished by the work of a "handicapper general" who is charged with weighing down all elevated gifts, physical and mental.

xvii. Even beyond the native gifts, we could never titrate the important advantages of proper nurture, rearing, coaching, encouragement, experience, or faith.

xviii. Would anyone be interested in watching a chess match "played" by two computers? If so, why? Would that be a "chess match" in any ordinary sense?

xix. These questions about mind, body, and their interrelation, we are well aware, are deep and difficult philosophical matters. We have no illusion that we have done more here than signal their crucial importance to the ethical analysis at hand.

xx. The perceived "at-one-ness" of the runner can produce a parallel sense of at-one-ness in the spectators, also manifesting mind, body, and heart. Unselfconsciously we spectators are stunned by the manifestation of genuine human excellence: it holds our attention, it takes away our breath; it wins our heart. In appreciating seamless excellence, we have moments of seamless excellence ourselves, sharing reflectively in the glory of the superior human performance we are witnessing. This "superior performance" of the spectators has important implications for the character of the whole society, a matter to which we return in the final section of this chapter.

xxi. To be sure, these transforming agents do not in fact produce a completely different body. And a steroid-enhanced athlete probably still feels that he is the same person he was before the treatment. But the fans, seeing him for the first time in his new physique, so suddenly acquired, often wonder if the newly minted slugger really has the same body, really is the "same" person. More important, the implicit aspiration, even in these modest transformations, is indeed to have a body more perfect than one could ever acquire simply by cultivating one's own natural gifts. In this sense, using these agents on one's muscles expresses the same desire as having major cosmetic surgery on one's face: to become, to some extent, someone else, someone with a more perfect body. The use of analogous agents on one's psyche-say, to acquire a superior temperament or a different set of memories-is likewise a (tacit) aspiration to become someone else. We shall explore this subject in Chapter Five, "Happy Souls."

xxii. For example: No sane person, we suggest, would choose to be the fastest runner on two legs if it required becoming an ostrich. And few people would choose to acquire someone else's perfections of body or mind on condition of becoming that other person. Who, in the event of such self-transformative improvements, would we say now enjoyed them?

xxiii. Though both are concerned with matters of life and death, soldiering and doctoring are different. The two "wholes" that they serve are different, the community being both more comprehensive and much less intrinsically perishable. The existence of all individual life within a community depends on the survival of that community. An argument could be made to cut soldiers a bit more slack than physicians in doing whatever it takes to "get the job done," precisely because the whole itself is at stake in time of war. A counter-argument could also be made, not on the basis of the superiority of the good being served, but rather the means used (cutting the body to heal it versus cutting the body to kill it), which might justify cutting more slack to surgeons than to soldiers.

beyond therapy: biotechnology
and the pursuit of happiness

Table of Contents

Superior Performance

I. THE MEANING OF "SUPERIOR PERFORMANCE"

II. SPORT AND THE SUPERIOR ATHLETE

III. MUSCLE ENHANCEMENT THROUGH BIOTECHNOLOGY

IV. ETHICAL ANALYSIS

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Footnotes

ENDNOTES

Next Chapter

beyond therapy: biotechnology and the pursuit of happiness

Table of Contents

Superior Performance

I. THE MEANING OF "SUPERIOR PERFORMANCE"

II. SPORT AND THE SUPERIOR ATHLETE

III. MUSCLE ENHANCEMENT THROUGH BIOTECHNOLOGY

IV. ETHICAL ANALYSIS

_________________ Footnotes

ENDNOTES

Next Chapter

beyond therapy: biotechnology
and the pursuit of happiness

_________________

Footnotes