Friday, July 25, 2003

CHAIRMAN KASS:  All right.  The sixth session visits the other large project that the Council has been carrying forward, the working title for which is still "Beyond Therapy:  A Progress Report."

This project, just to remind you, is an inquiry into the available uses of biotechnology that go beyond the healing of known disease to achieve a variety of possible other human goals and satisfy widespread human desires both worthy and unworthy.

And despite the difficulty of working on this topic, there are many disparate technologies.  The concerns are inchoate and very complicated.

We have agreed to pursue this topic for public discussion for a number of reasons.  First, it gives us an opportunity to talk about the ends or the goals for which these technologies are to be used and not simply the safety, efficacy, or the morality of the means.

Second, it bears upon the question of the nature and meaning of human freedom and of human flourishing.  It addresses the alleged promise touted by some of some super humanization and the alleged threat deplored by others of dehumanization.

It also compels some attention to how these technologies force us to ask the question of what it means to be a human being and to be active as a human being.  And although some of these things are in the future, the current trends make it perfectly clear that the push beyond therapy is already upon us in performance enhancing drugs, in mood altering agents, and the like.

Also, some of these issues are of special interest in a free society where the presumption in favor of the private uses of many of these things to improve our lives might have consequences in the aggregate that feed back upon all of us in which we might actually regret the consequences of allowing everybody to have the benefits of their own free choice.  Choosing sex of children would be just one possible instance of that.

In educating ourselves, we had presentations from experts on drugs that affect behavior, mood, and memory.  We had presentations on drugs and genetic modifications that would affect athletic performance, on choosing sex of children, research on aging and the life span, genetic alterations of muscle, and the possible enhancement uses of PGD and directed genetic change.  And we had staff  working papers on all of these things which were discussed.

In working toward presenting our reflections in this area, we decided to organize the presentation not around the technologies themselves, but rather around the desires and the goals that either drive our interests in these techniques, a desire for longer life, or that will enlist the available powers that they make possible, desires for longer life, finer looks, stronger bodies, sharper minds, better performance, happier souls.

And this enables us also to think about how these new biotechnological powers fit with previous and present human pursuits and aspirations, not necessarily mediated by technology.  I think that's one of the interesting benefits of regrouping them in this way.

You've been reading some of the materials that have been organized along these lines in connection with the desire for better children where, surprisingly, we've tried to put together in one analysis things that might improve the native capacities of our children through genetic alteration and improving their behavior through behavior modifying drugs and materials that discussed enhancement of performance, whether enhanced, say, by steroids or by genetic alteration of muscle and the like, and there will be materials to come.

I think everybody should remember that the spirit and purpose of this enterprise is educational and not primarily political or practical.  There are urgent things that we've been called upon to address, and we're going to try to show our ability to address those, but here we want to take a step back and look at the larger field to try to sort out fact from fiction, real technological possibilities from merely imaginary ones, to clarify in an educational way the ethical issues both for individuals and the larger society.

We want your careful comments on the materials that you are now reading and will be soon receiving, but I think for today we would like to have some general comments on the organization along these lines and also on some of these substantive issues that we have flagged for your attention along these lines.

And I don't want to give, you know, a fully account, but enough to at least elicit the kind of general reflections and responses I think that would be helpful.  Specific comments on drafts as they emerge we will certainly welcome.

Of course, in all cases one is interested in the benefits and the possible benefits of any of these new technologies.  Of course, one is interested with questions of safety.

But when one thinks about the application of genetic technologies to begin to possibly select offspring for traits, something that was discussed for us by Francis Collins, there are questions that have to do with parental responsibilities, questions about genetic discrimination and quality, questions about parental responsibility and the possibilities of changing attitudes towards children.

In the choosing of sex of children, there are questions about the limitations of liberty, of reproductive choice.  There are questions about sex discrimination, and again the questions of parental control over the quality of offspring.

And when you think about the seeking of better children with the behavior-modifying drugs, there are questions of social control and conformity, and the questions of the medicalization of moral education, and finally, a kind of larger question about the meaning of childhood altogether when it is all simply bent on enhancement of performance to meet certain kinds of external standards.

In the discussion of the pursuit of superior performance with the use of athletics as a model, not because we think that's the only activity, but that's somehow visible to us, it's important for us to try to distinguish between how biotechnology would differ from, let's say just better weight training or better diet and the like.

One has to think about questions of fairness and equality in those activities where superior performance is competitive, and one has to think about questions of the overt coercion of the sort one saw with the East German swimmers and the more subtle coercion of the sort that I believe it was — was it somebody who was counseling one of the San Diego Charter linemen?  Was it you Paul? — about unilateral disarmament in a world in which all of the linebackers are on steroids and the poor running back is at their mercy.

But also there are questions, perhaps the most philosophical question, in that kind of discussion about the dignity of human activity, for lack of a better word, about the relation of the doer and the deed and the difference between acts of humans and human acts, that is, acts that somehow reflect and flow from our humanity, things in which superior performance is somehow related to the things that we do as opposed to the things which we are merely passive and don't result from our own exercise.

And in all cases, the question, in a way the most interesting question and the hardest to get a hold of is never mind what this might mean for individuals.  What would it mean to live in a society in which this kind of practice were generalized, in which the performances were all enhanced of that sort or you couldn't somehow tell who was or who was not in this way enhanced or in the case of children, what would it really mean if one begins now to have — in a society in which somebody was saying earlier in the meeting in which there are high pressures to buy one's way into the nursery school at the 92nd Street Y, where some of those advantages could be had also with pharmacological agents that would improve the behavior, attentiveness, and ability to learn.

So those larger questions about the social character are there for discussion.  I think the real question is about the organization and whether these issues that have been identified are germane and an opportunity actually even to discuss some of those issues here.

I should say, by the way, on a subject of concern to several of us, well, we have, I think, in the spirit to, on the one hand, try to dispel certain kinds of worries that seem to be unnecessary.  At the same time, without exactly prophesying the future, if there are identified areas of concern, I think it's incumbent upon us to at least put them out there for consideration so that they can be studied and investigate, at least aware of the kinds of things that are at stake.

So that sometimes the tone will strike some of you as unduly worried and in other cases insufficiently so.  It's difficult in this area to strike the right balance, and we take your guidance on that as well.

I hope that's enough to produce some responses on the basis of the things that you have been reading and are now able to anticipate as well.

Gil Meilaender.

PROF. MEILAENDER:  Well, there's a whole range of things I'd be interested to talk about, but let me just make two comments right now.  One is really no more than a comment on organization.

The direction the staff is moving now and inviting our response to is one that is a little different, in fact, from what we had been talking about, at least in the sense that we had kind of latched onto the most obvious organization principle, namely, certain case studies as kind of just examples to be taken up in their own right.

And the attempt now is to try to think of these in ways that cut across the normal lines, organized under various human desires.  And my comment is simply to say I think that's quite good. 

There are moments when it does seem counterintuitive.  I mean the combinations are at first sight strange, but what it suggests is that it's not so much in many of these cases that we're trying to take a case and sort of, as it were, vote up or down on it, good or bad, but that rather we're simply trying to say here's what a very different future may look like, and to see these different things organized in these ways seems to me to be a kind of promising way to do it.  So I rather like that.  That's my comment on organization.

Then a second is — I guess it's still a comment, but it's not quite as positive — is related to that insofar as this is an attempt to organize things around goods or goals or aspirations and not means questions.

That's fine.  As I say, I like the organization, but I'd want us to be careful how we formulate that connection.  So that, for instance, if we talk about parents selecting out certain children or selecting in certain children, I'd want us to try to avoid a certain tendency that I think easily crops up, given that we're focusing not on means so much, but on goals and aspirations, and that is to suggest that the one is weightier than the other because it's concerned with goals.

I mean, I would say that though it's good, we should have a lot of concern about selecting in children for various reasons, what's really central to our concern in this project, a certain kind of continuity with parental responsibility, you know, that you're trying to help your child and improve the child in various ways.  It does stand in a certain continuity with it even if problematic and dangerous in certain respects.

Selecting out I have a much harder time understanding as standing in any kind of continuity with ordinary parental responsibility.  So I'm happy to have a focus on selecting in, but what I don't want us to do is suggest that we have, therefore, somehow it upon the weightier question.  It's not weightier.  It's just different and deserves attention in its own way, but I'd want us to be careful how we formulate that.

CHAIRMAN KASS:  Thank you.  A point well-taken.

Paul McHugh.

DR. McHUGH:  Well, maybe I can slip in here.  I'm not sure it will be helpful, but it kind of backs up what Gil is saying.  I believe that this is a very important enterprise we're beginning here, and that the general principles that will come out of this will teach us a lot about what we are preserving in the ethical principles related to biotechnology today.

And again, because I'm a clinician, I'm always seeing the down sides of all kinds of things, and I want to emphasize that, therefore, I'm very conservative about any of these enterprises that want to enhance things simply because I've seen how that concern with enhancement, and particularly the concern with the biological nature of people begins to get folks to look at their vulnerabilities or the little bit of red ink that's in their life and neglect all of the black ink, all of the wonderful assets that they have.

And I think I've talked to the group before about the fact that, again, in my clinical life at least once a year I have very talented parents bring to me a young man or woman that is not living up to Daddy's achievements.  They're usually people who have IQs of 140 to 150 and their kid has an IQ of 125 because there is this reversion towards the mean.

And they're upset that the kid is not, you know, valedictorian.  Now, this kid, let me just describe for you.  This kid is six foot, two.  It's from mid-court nothing but net, you know.

(Laughter.)

DR. McHUGH:  He's absolutely the most attractive soul you can imagine and they're wondering, well, why isn't he valedictorian, and my job is to persuade them that their other things in life and other things about this person that they have to appreciate, and that I'm appreciating just by meeting them.

And my job, and by the way, it's not to hard eventually to persuade them that there are many, many assets that need to be emphasized.

I believe, in fact, that it goes beyond this little, small story that I'm telling you.  I believe that part of our problem for young adolescent people, particularly young adolescent people who are high achievers themselves, who are already with 1600 SAT scores and the like, that somehow or other in the challenges that they face ultimately in places like Cal. Tech. and MIT, they begin to believe that somehow that they don't quite measure up, and many of them want to check out because of that.

And I think that has come about in part because of our assumption that we are simply machines, that maybe we don't have all the right gears for, and the suicide rate amongst adolescents, as you know, has gone up very remarkably, and it has gone up, by the way, amongst very talented adolescents.  And places like MIT are very much suffering from and trying to figure out how to work on it.

So I'm very anxious for us to talk about the goods of human life itself, emphasizing that the assets are important to preserve even as we think in terms of what can we do somewhat to help people.

Ultimately what am I trying to do?  Am I trying to teach people? 

I am trying to teach them to — well, Bill put it so well — to savor their lives and the like, and I'd leave you with perhaps an old chestnut about enhancement.  Just maybe many of you know it.  So it's a corny story.

It's an old Yogi Berra story.  You remember Yogi Berra, the Hall of Fame catcher, and one day in a long, hot game, a batter came to the plate, and he was a religious person, and he was blessing himself three times, and Yogi said to him, "Why don't we just let God watch the game today?"

(Laughter.)

DR. McHUGH:  And to some extent I want to tell people, "Can't you watch the game and see what happens?" with the emphasis, therefore, on the parent to say, "You have a lifetime experience with this gift that you have.  At first you're going to be spending a lot more time monitoring and shaping and advantaging the child, but ultimately you are going to be somebody who watches the trajectory of this life in a very special way, a way of concern but in which you do not any longer fool with the instruments but let the life go on enriching all of us."

And so I think this is a very important part of our things to talk about.  It's as important as any technological thing primarily because of what kind of a message that we want to give people.

CHAIRMAN KASS:  Thank you.

Michael.

PROF. SANDEL:  Well, I, too, think this is a very important topic, and I think the organization is a good one.  One question I had really, and I don't know if this is the time to delve into some of the actual ethical analysis that this question raises, and my question has to do with, well, one that we have discussed here on other occasions when we've talked about sports, which is:  why does it seem okay for an athlete to improve herself through training, but not through bioengineering?

We've wrestled with this question before, and in trying to get at the heart of the ethical issue we've put to one side obvious safety considerations, and we've also discussed the question of fairness in the competition.  Would it give an unfair edge if some had access to the bioengineering but not others?

But we've agreed that there is a further moral question.  Assuming it were available to everyone and assuming it were safe, what would be wrong with bioengineering of athletes?  And why is it disquieting in a way that training regimes which enhance are not disquieting?

Now, one answer to that question locates the moral crux in the idea of human activity.  This is what you've referred to here, Leon, and also on previous occasions.  And the answer goes something like this:

What's wrong with bioengineering superior performance is that it undermines the dignity of the performance of the athletic excellence by detaching the doer from the deed, by introducing what you've called on various occasions the kind of biological magic so that the athlete who trains rigorously is in some ways less alienated  from her performance than the athlete who simply takes a pill or has an injection of a gene of some kind to enhance the performance.

And that you've argued — and here I just really want to raise a question about that argument — that's the moral crux of the issue, the alienation of the doer from the deed, and here I have two questions really as a way of inviting you or others to say whether this really is the moral crux of the disquiet.

Between training and bioengineering to improve performance are other means that normally we don't find disquieting, like taking vitamins or improving nutrition.  But taking vitamins and improving nutrition is a way biologically of improving ones body in a way that is as much biological magic as the gene vector, well, except to those who may be medically informed and who might be able to give us, as Dan could, a detailed account of how the improved nutrition or this vitamin actually leads to improved performance.

But then Dan or others could also give the same explanation of the gene vector.  So as far as the idea of authenticity, being in touch, the doer and the deed, keeping them in contact, is there a difference or does this analysis suggest that maybe we should feel disquiet when some athletes undergo nutrition and vitamin regimes?  That's one question.

The other question is:  why do we worry, if we worry, about the dignity of human activity, about avoiding the alienation that comes when we indulge in biological magic to get a result rather than training?  Why don't we worry about that in the case of healing?  Why is that only a concern in the case of enhancing?

If someone needs surgery or a medical procedure to heal an illness or a disease, why don't we worry about the dignity of human being in the world, activity in the world then?  Why don't we worry about the  biological magic of medical therapies?  Why is it only a concern in the case of enhancement?

PROF. MEILAENDER:  May I just piggyback on that? 

CHAIRMAN KASS:  Please.

PROF. MEILAENDER:  I'm not going to answer his questions.  I just want to exacerbate them in a way.

But to come from the other side, in a sense, from the point of the person who has used the genetic enhancement, it's just worth noting that I think it would be true to say that at least in many cases this wouldn't eliminate the need for continued training regimen, for working on your skills, for plotting strategy for all sorts of things.  It wouldn't mean that you were necessarily interested only in winning.  You could still enjoy the performance itself, though perhaps at a level you couldn't otherwise have done.

So that, in fact, many of those things that we probably have no objection to would still continue to be part of the athlete's package even at an enhanced level, and that to me, as I say, it only complicates the question still further.

CHAIRMAN KASS:  Dan and then Mary Ann.

DR. FOSTER:  Just one question.  I don't like the analogy — I would rarely disagree with Michael about anything — but I don't like the analogy of healing or treatment as part of the thing because what medicine is doing by its treatment is to try to prevent destruction of the organism, whereas the use of these other techniques that you call biological magic are to enhance superiority.

So I don't think that that aspect of it is equivalent along those lines. 

The only other thing I would say is it's pretty interesting that the sports community itself in some sense intuitively has said we need to keep the competition competition without enhancement.  And so they penalize if you take adrenal steroids or that you take Ephedra or, I mean, if you've got an allergy or something, you know.  I mean, you've got asthma, and you get eliminated from the Olympics because you might get some more, you know, adrenalin equivalent to do that.

So we have a very broad aspect of human experience.  I mean, the East Germans, the horror of what they did to those women swimmers and so forth was just awful, but that community which so far as I know is not primarily involved with ethical issues; they're involved with winning, but they want to win fairly; have said that this is something that intuitively seems wrong to them.

At the end of this document, you know, there's a statement about the computer chess player versus the human chess player, and in some sense it's a little stretched, but in some sense it is not about the game anymore because the computer does not use the same — it doesn't sweat.  It doesn't intuit it, doesn't watch to do that.

So it's interesting to me that the participants in the issue of sports have already decided universally, and when they're not doing it, there's huge criticism about the fact that they're not eliminating enhancers.

Now, you could argue if it's available to everybody, then it would restore the competition.  You know, if everybody took the same amount of adrenal steroids and so forth, then you'd get the competitive thing there.  But it is interesting that they sort of sensed, and I have to say that I think I sort of sense that there's something flawed in this thing beyond.

I think training is different.  I mean, I just think it's intuitively different because it's a matter of work rather than a matter of making something biologically happen.

And I should say as a physician, all of you know that there are very serious side effects.  People who use steroids and so forth die earlier, you know.  I mean, the men's testes shrink.  I mean, there are all sorts of - they build up muscles, but there are great prices that are there, too.

So I just wanted to make those two points, that I don't think we ought to use the biologic magic in medicine as an equivalent to that.

PROF. SANDEL:  Just, if I may, a point a clarification.  I was unclear when I spoke.  I did not mean to equate medicine with sports enhancement.  To the contrary, I'm for medicine and I'm against sports enhancement.

What I was suggesting was that the reason that Leon has offered for objecting to enhancement is problematic because if it were applied to medicine, it might condemn medicine as well as enhancement.

So I was trying to identify a feature of the argument against enhancement, not to suggest that medicine is the same as enhancement.

DR. FOSTER:  That is one of the most gentle responsive criticisms I've ever heard.  What he said is I didn't understand a word he said, and I wouldn't have said what I said if I'd really understood him.

(Laughter.)

DR. FOSTER:  And so that's gentle.  That's putting the blame on the receptor rather than the agonist, you  see.  I mean, I've got perfectly good agonists here, but my receptor was not in the right mood.

So I accept.

(Laughter.)

CHAIRMAN KASS:  Well, that kind of generosity only moves me to come to your aid, sir.  You shouldn't be so - Mary Ann, do you want to get in first?  Because I'm accumulating a number of things on the substance that I'd like to respond to.

PROF. GLENDON:  Yes.  Well, I want to go back to Michael's presentation where he said that training regimes are not disquieting.  I don't think we can say that easily, and reflecting on that caused me to think that perhaps although I see why we took athletics as an easy example, I think maybe athletics and the role it plays in our society, maybe it's not such an easy example.

I'm thinking of the story of Mickey Mantle as a young boy.  His father took him out.  He had no childhood.  His father took him out in the back yard and relentlessly pitched to him day in and day out and created a certain kind of being who was a very skilled athlete, and a human being who was lacking in several qualities that one might think associated with a full human life.

And I think from what one reads about the training of tennis players and Olympic athletes, there are many, many young people whose childhood has been taken away from them and to the point where I'm not advocating this, but suppose there were a pill that had no side effects.  Which would be better for the realization of a full human life for an athlete, training day in and day out or popping the pill?

CHAIRMAN KASS:  Very nice.

Before there are more, let me make some kind of response.  First of all, we're really wrestled very hard with these distinctions, and part of the discussion is to try to figure out, well, why are biological technical means different, and there is some discussion about training and various other things.  And you line these things up on a continuum, and it's sort of hard to know the boundary, especially when you recognize that anything that you do brings about a transformation in the body, and the mechanisms might be very similar.

And putting this not with a biotechnological focus but in the context of the human desire for superior performance, it enables one to cast reflective light exactly on the kinds of excesses of training.

I recommend this to everybody.  While working on this stuff, we rented the video ofThe Chariots of Fire, which is for those of you who don't know it at all really one of the great movies in the last couple of decades, and it's about the 1924 Olympics in which one of the British runners is chastised for having a trainer, which was absolutely unheard of in British amateur athletics to that point.

And what I had forgotten was the Americans showed up at this Olympics, all of them with trainers and already engaged in a highly methodical approach to the body. 

When Ted Friedmann was here and he was sort of mournfully speaking about the death of the athlete understood as the amateur acting out of kind of love of the activity and the concern for victory and then ultimately the separation of the achievement from the achiever.  So the only question is how far did the ball go, in which you begin to turn your performers not so much into athletes as entertainers.  The activity gets to be deformed.

You can see that with training.  I mean, you can see that with a certain kind of excess of training, and I think the point is very well taken.

And the next point is to say that the analysis ought not to be to try to definitively answer this question, but to try to provide the kind of language for the ongoing consideration of this question, and we've gotten in the discussion multiple possible reasons for being troubled by this.

To defend the argument, and this would take a long discussion and maybe we should just start, it does seem, to me to come to Dan Foster's aid, one could say that in the case of providing insulin to diabetics, one is coming to the aid of a body seeking to heal itself, and that while the mechanism of action is not known to the patient and from the patient's point of view it might just as well be magic, it nevertheless is an attempt to serve a particular kind of given goal and to come approximate the way in which the body does this on its own.

Whereas in these other areas, it seems that ordinarily we get to be excellent by activity in which we sense the connection between practicing the piano and getting good at play, which there is a kind of connection between the mode of improvement and the thing being improved.

In fact, you improve in the various activities that you train in, and to that extent on the point of human experience, there's a certain intelligible relation between training and the thing that is perfected.

And to that extent there does seem to be some kind of disruption, though I want to acknowledge Gil's point.  When it's not talking about giving somebody a pill that's going to make them out to be able to hit the three point shot, training and practice still will be necessary.  So it's not simply a magical pill that replaces that.

But I do think healing is -

PROF. SANDEL:  Healing is different you're saying because it's a worthier end than souping up performance, but that has nothing to do with the -

CHAIRMAN KASS:  No, I don't think I'm saying it's a worthier end.

PROF. SANDEL:  Then what's the distinction exactly that you have in mind?

CHAIRMAN KASS:  I'm saying that one enters into the healing activities and supplies biologicals to the body to aid the body's own self-healing process.  Look.  We function all the time without awareness of the biological processes that lie beneath all the things we do and experience. For example, we speak and make ourselves understood without being aware of everything that makes it possible for us to speak, and that takes place beneath the plane of consciousness. Of course, a scientist can try to analyze the biological mechanisms, but from the point of view of human experience, if you stop to think about it, speech and understanding remain absolutely wondrous and mysterious, inexplicable in the language of biology.

I mean, who knows how it is that little things of sound fly from over here across there and carry units of intelligibility?  These are the same biological processes that are in the same sense that we use the term "magical." 

So I grant you that this invites a kind of reflection of the way in which our bodies are somehow mysterious to us, but there are many ways in which we go about improving our ability to use our bodies that proceed by activities that in their human import are intelligible.

If I practiced the piano, God willing, I would get better at it as a result of practicing, and similarly in various kinds of training.  So that one sees through the ways in which we use our bodies deliberately to improve the activities, there is a certain continuity between agency, accomplishment, improvement.

PROF. SANDEL:  And so what about the vitamins or good nutrition?

CHAIRMAN KASS:  Yeah, look.  I want to acknowledge continuity.  I don't think the disquiet depends upon one's somehow crossing some kind of bright line and saying you're in a terrible - although I could say vitamins and good nutrition are -

PROF. SANDEL:  Would you say a little alienating?  It's a matter of degree.  So they're a little alienating and, therefore, a little disquieting, but not as much so?

CHAIRMAN KASS:  You'd have trouble getting me on good nutrition and vitamins.  I mean, it seems to me one could make the case for good nutrition and vitamins just in terms of being healthy and fit.  If the question is whether I should give up eating a healthy diet in order to eat only those things that will make me a terrific wrestler, if any such there be, then I think you're in a different territory.

I want to acknowledge the difficulty, Michael.  I don't think one's got a kind of bright line on the other side of which you have the principal basis for disquiet, but this is a struggle, I think, to try to figure out.

And the other alternative is to say control as such is bad.  Let God enjoy the game today.  And that merges in with the hubris objection that you've raised previously.

DR. FOSTER:  I only want to make one response about vitamins.  Most of that is mythology, as the Institute of Medicine said.  What's characteristic of vitamins, they act in very tiny quantities and they're not needed above that, and if you eat an average American diet, everything is so filled with vitamins that you can't be vitamin-depleted.

You know, if you're a Zen Buddhist, you know, you have to do that.  So most of this stuff that the athletes gulp down goes out in their urine within 24 hours.  So I mean, what they're doing is they're trying to enhance the health of the sewage or something, you know.  Like that's -

CHAIRMAN KASS:  And the vitamin-producing industry.

DR. FOSTER:  But it has a big psychological effect.  Now, there are exceptions, but then when the exceptions are the vitamins are not acting as vitamins.  Vitamin E may be an antioxidant and keep you from getting atherosclerosis, but it's not acting as a vitamin.

So this is mostly mythology.  So the enhancement is due to the psychological view that I'm building myself up, and not from any biological magic in that sense.  So I would say forget about the vitamins.  Okay?

(Laughter.)

CHAIRMAN KASS:  Gil, still on this point?  Yes, quickly.

PROF. MEILAENDER:  Yes, two comments.  One, we've tried to get, in the Beyond Therapy project, we've tried to get beyond the therapy enhancement distinction, and I do think that that distinction does not fully work and does break down at some points.

But there is a sense in which maybe we shouldn't try to get too far beyond it because it has reemerged in a way.  Why good nutrition?  Health, you know.  It has got nothing to do with enhancement per se.

And so in our, I think, correct effort to see that that distinction is far more complicated than it has often been thought to be and that it will not just in itself solve the questions we're taking up, we should be careful not to go too far because, in fact, it just reemerges at certainly places.

CHAIRMAN KASS:  Right.  Point well-taken.

PROF. MEILAENDER:  And we need to see that.

The other point I just wanted to make -

PROF. SANDEL:  But then, Gil, just to enter, that's then back to the end.  The end of health is worthier than souping up athletes.  It has nothing to do with this particular thing about the dignity of human activity and about making the individual's agency less humanly or experientially intelligible.  No, it's that we consider health is a higher end than souping up athletes.

PROF. MEILAENDER:  I don't know about higher.  See, it's the worthier/higher language.  We probably agree at some level, but it's pretty low to the ground good, in fact, in some ways.  It's not the kind of thing I use "worthy" in connection with.

May I make one other related point?

CHAIRMAN KASS:  Yes, please.

PROF. MEILAENDER:  I don't generally disagree with Mary Ann.  I agree with her about 12 year old gymnasts, say, or something like that, but it is the case if what we're interested in is thinking about superior performance that almost all superior performance requires an imbalanced, an unbalanced life in some respects.

And I would be sorry not to have been able to watch Mickey Mantle do what he did as well as he did, and I'm old enough that I did watch him.

Now, he paid a price for it.  I can't say that he should have paid the price for it.  On the other hand, the superior performance might not have been possible without it.  So I'm always unsure what I think about arguments about a balanced life.

Most of the good things in the world come from people who aren't so balanced.

CHAIRMAN KASS:  Jim Wilson and then Bill.

PROF. WILSON:  I want to try an argument about which I am most unsettled.  So I plead with you not to spend the next hour pointing out the obvious faults in it.

At the end of the paper, the author mentions watching Gary Kasparov play a computer, and Gary Kasparov is one of the great chess geniuses of all times.  There was no doubt in my mind that eventually somebody would invent a computer who could beat him, and it did.

But that was an interesting thing to watch, but then the author of the paper goes on to say, "Would we watch two computers play chess against each other?"  I don't think so.

So there's something about the humanity of Kasparov that is important.  No matter what he went through in childhood suppression and growing up in an oppressive state and learning chess as if nothing else mattered and leading so far as I know a monomaniacal life, he was a human being.

So that there's something about humanness that counts, but that then raises the question of therapies of various sorts that are designed to enhance it, and I want to say that I'm not sure we should hold constant the possibility that all enhancing therapies are equally safe because as I think about this, I want to make distinctions. 

People take adrenal steroids, and as  Dan has pointed out quite correctly, these have some very adverse effects and objecting to this behavior on the grounds that you're sacrificing your humanity in order to advance your ability in one particular area, that is to say to confront a middle linebacker of the San Diego Chargers, seems awkward.

But on the other hand, suppose you have asthma and suppose you can take a drug that eliminates the asthma or some other thing, which is on the prescribed list, or suppose you suffer from cluster or migraine headaches and you take drugs for that or suppose you have other things for which you take drugs which have some side effects, but not the kind of side effects that are disabling. 

It seems to me that in time society might drift in the direction of saying we're going to loosen up the list of drugs that you cannot take, and we are going to be more precise about specifying those drugs which in some sense are inhuman.  That is to say if you take them, you are courting almost certainly extremely adverse side effects which diminish your humanity, and to allow more drugs that solve particular problems and have an acceptably low rate of risk.

Now, since I have thought this through only in the last 12 seconds, I'm sure that by tomorrow morning I may be reconsidering my remarks, but I don't want to assume that we have to analyze this on the assumption that all drugs are safe because all drugs are not safe, and all drugs never will be safe.  And we have to realize that one of the reasons we are concerned about this problem is that the unsafety of some drugs makes it a little bit more like watching two computers play chess.

CHAIRMAN KASS:  Thank you.

Bill Hurlbut and then Elizabeth and then Paul.  Bill May, I'm sorry.

DR. HURLBUT:  Dan mentioned the East German swimmers.  I think it was about 1964 that the first real use of steroid drugs became evident in the Olympics, and I remember reading an article.  One reporter said to the coach of the East German swim team, "Why do your swimmers" - this is a female swim team - "why do your swimmers have such low voices?"

And his response was, "We didn't come here to sing."

And it raises the issue, well, what is the overall purpose of a thing anyway.  And I think that's the context in which we have to look at this kind of an overspecialization, which is what enhancement is aimed at.

I keep saying in these discussions, and I think we need to keep this in the forefront of our minds that what are the purposes behind enhancements anyway.  Competition can have both a noble and a very negative overtone to it, and yet I think we have to bear in mind what the purposes of human existence actually are, and what are the qualities that we as biological beings have that are special to both our functioning and our sense of meaning.

And I keep coming back in my mind to the meaning of allowing yourself to be specialized, which is what Gil was referring to.  A lot of great things come from narrowed, focused specialization in human existence, but something else really great comes from not specializing, and that is a broader, what you might call a breadth of comprehensive engagement with the world.

And here I come to think of what's called focal dystonia, which is a phenomenon you see among what's common among concert pianists or classical guitarists, where they work with such focused attention on a single task that they actually become semi-paralyzed in their performance of that task, and they have to give up - Loren Hollander, for example, a famous pianist, developed focal dystonia, and he couldn't play the piano even though he had been a very successful child prodigy.  And he realized that what he had done was he narrowed his life in such a way that he actually destroyed the breadth of his performances and his ability to perform even in a specialized way.

So the lesson I would take from that is that what is strong - the reason the hand can do what it can do is because it has a broad experience and then can apply that broad experience to a particular narrowed function.

Maybe Paul will have to help me out with what I'm trying to say here, but likewise taken in its breadth, the human fullness, if you're coming to do something more than sing and win, if you're coming to have a full, rich, human meaning, which we are now coming to call a spiritual meaning in our society because that's lifted us into a pluralistic realm that is also yet related to something larger, transcendent that goes behind the individual, but isn't specifically religious; if we're going to seek that breadth of comprehensive significance, then we have to specialize in such a way that it is part of that and not an isolated focus that destroys the meaning of the whole.

I don't know if I got that across really, but dignity to me means fullness, and fullness means a truly meaningful, engaged purpose, not just winning.

CHAIRMAN KASS:  Thank you.

Elizabeth, Paul, and Bill.

PROF. BLACKBURN:  A general comment on the organization.  I thought it was very useful to bring it into the large questions like this and not break it down just into technologies.

And I had a thought which struck me upon deliberating on this and also as our discussion proceeded this morning, and I'm somewhat disquieted by this term "magical" and "mysterious," not that I want to deny the complexity in our lack of understanding of a lot of the processes that go on, but there are a couple of things that I didn't really like about this, and one was that it sort of implied that there is sort of an abdication of the need to really think and grapple intellectually with what's going on.  Somehow if you just throw it into "magical" and "mysterious," that sort of says, well, okay, we don't need to think about it anymore.  And I think that's a sort of anti-intellectual thing that I felt uncomfortable with.

And then slightly implicit, I thought, in some of the discussion and perhaps the writing was the idea that, well, it was mysterious.  Dan would understand it, but those simple athletes wouldn't, and I thought that's sort of, you know, perhaps even a little condescending to sort of imply that, oh, it's mysterious and magical to those people because they can't really think about these things properly.

And so I think perhaps avoiding those terms as much as have been used would be helpful because I don't think we want to just, you  know, abdicate thinking about them.

CHAIRMAN KASS:  A quick response.  Anything that smacks of being anti-intellectual will come out.  There is notoriously a disjunction between the way science understands things and the way human beings on the plane of human experience understand things.  These are two different languages.  It's a vexed question of how these things fit together, whether you take it up under the mind-body problem or consciousness or what have you.

And when Michael said that Dan would understand this, I think he was saying he could understand the mechanism of this, but I'm not sure that the mechanism of it is identical to the experiential knowing from the inside.

One can find a way to say that without appearing to be insulting, and on the subject of mystery, this is, I suppose, a long discussion and not for here, and the question is when scientists use the name "mystery," they usually mean it as that which we do not yet understand, but that in principle everything is capable of having an explanation.

And I would at least like not for the document, but for the continued reflection of everyone around the table to wonder whether that's true.

PROF. BLACKBURN:  I think perhaps "magic" is the more objectionable terminology.

CHAIRMAN KASS:  Indeed.

PROF. BLACKBURN:  I see what you're saying about "mystery," but "magic" to me sort of implies something, you know, that's the last resort, is to call something "magic."

CHAIRMAN KASS:  Terrific.  Thank you.

Paul McHugh and Bill May.

DR. McHUGH:  I have only a couple of things that I want to add to what I said at the beginning about nature itself and, in part, in relationship to what Mary Ann and Gil were talking about, and that combines the issue of science and, interestingly, simple observations about human nature.

It turns out that child psychiatrists have observed the schools that do best with the children are the schools that offer a smorgasbord of things for the kids to do, not just reading and writing and athletics, but dance, art, other things.

And it turns out that the children themselves seem to become thriving adults if at some early time in their life they discover that they were a success at something, and you never know what somebody is going to be a success at.  So, therefore, lay out before them music, dance, art, reading and writing, math clubs, stamp clubs, train clubs.  Okay?

And it works out that they do well, and then it comes around to the other side, to this Mickey Mantle issue.  It turns out that as you see people emerge as kids and come into their adolescence and early adulthood, they begin to narrow down the things that they want to do, and there is a sense that everybody, at least the happy ones, put themselves through boot camp at some point.  Okay?

I've got to do this even though it means I'm going to have to give up a lot of other things because, darn, I want to do it at the best level I can.  I want to play every day at the big league level, and to do that means I've got to do something else, give up something else.

And those two things are natural, and we as parents or as other people want to encourage that to happen for all of our kids.

CHAIRMAN KASS:  Thank you.

Mary Ann, to this?  Okay.

PROF. GLENDON:  I just want to emphasize and partly in response to what Gil said that there's a big difference between a child's reaching the level of maturity where the child decides he or she wants to go through boot camp and having the parent put that child in boot camp from three or four years old.

And so this general question, and we shouldn't forget that this general question is coming under the heading of better children and under the heading of big questions about are we doing things that are transforming the meaning of parenthood, parental responsibility and childhood.

CHAIRMAN KASS:  Bill May.

DR. MAY:  I wanted to return to the question of the spirit of reflection in this area.  I've spent 52 years teaching.  I'm finished with it now in the classroom, and I just think that work on these two topics that I've had a little chance to look at would be wonderful teaching material. 

So much medical ethics has been quandary ethics.  I mean, you identify a problem, and then you hunt around for moral principles that will resolve your problem, and you go from one thing to the next and some other problem.

And to think reflectively about better children and excellence of performance offers a kind of meditation on the human condition that I think would be very attractive.

And the word "mystery" was used, but I think it offers the possibility for the stirring of wonder in young folks, the kind that I've taught across 52 years.  I mean, we're not doing this for the sake of developing a preamble to regulations.  We're doing this to provide an educational resource, it seems to me, and it seems to me that what I've seen so far would really allow for that.

Now, just a couple of comments on the parenting and then excellence of performance.  On parenting I think I may have mentioned this earlier and maybe it's time to close shop if one begins to repeat things that one said earlier, but I overlapped one year with W.H. Auden at Smith College, my first year of teaching, and we happened to be in a faculty show together, and so I got to know him, and he was talking about the pressures that American children were under as opposed to English children, and he said in America the very act of being an immigrant nation, except those who were forced to come here, had a huge pressure in the direction of outstripping your parents.

And we place a lot of this in that setting, to produce better children, and behind that lies the whole aspiration that people came here maybe not because they thought they were going to produce better children but a better environment that would allow their children really to outstrip, and they put up with very considerable sacrifices in many cases of a strange language and all of the rest that tended to shrink the parents and justified this sacrifice in terms of what it would do for the kids.

And we've not only been an immigrant nation, but in a sense, a perpetually migrant nation.  The mother ship then became the education that would be offered that would allow kids to move out of the ghetto neighborhoods to which my grandparents came, and then you move out of that.

So it seems to me it's a very worthy enterprise to deal with this whole business of producing better children and then talking about what happens in the setting of biotechnology that feeds into this very fundamental aspiration in the kind of society that we are.

On the other issue of excellence of performance, what I've seen of it especially in theater, by accident in my own life, so often you see the need for a double gift of both the talent and a psyche to support the talent.  And one talks about training the talent, but there's the need for the discipline of the psyche.

And it's very interesting.  One is talking not simply about things that will enhance a talent, but those things that will sustain a psyche to support this talent under special pressures, and they are huge pressures, especially public performance.

What was it in the setting of

Greece?  Truth, alethia, moving out into the unconcealed, and that's a terrific transition from life that's concealed to life that is displayed.  In the sense of being tested by that, you show what you are, and it's a very difficult and demanding task.

And so the huge temptation to find supports that will allow one to do this, and then not psychic supports, but then instrumental supports and the huge embarrassment for that bat to crack and splatter and cork to be revealed, and so what seemed to be displayed is very unfortunate.  In so many ways an utterly admirable performer, and I tend to accept his story about that.

(Laughter.)

DR. MAY:  But it's very interesting him blurting out as opposed to stepping out into unconcealment and showing your stuff as a performer.  It's a terrific collapse, and behind this, behind what I've looked at here, I couldn't help but think of Montesquieu.

And I had to give a lecture once at Meilaender's institution, Valparaiso.  It's before he got there, and it was on the honor code because that was a big thing at that school, and so I tend to read Montesquieu on that, and I realize the difference between the competitive meritarian (phonetic) society where in cheating you perpetrate an injustice on somebody else.

In the setting of aristocratic past, in failing to live up to the honor code, it's not simply an act of injustice against others, but an act of self-diminution.

And I think this document interestingly deals with that.  It may end up rather too much harkening to an aristocratic past.  The hand and spirit of our Chair shows through in this.

(Laughter.)

DR. MAY:  But so be it.  I found what I've seen so far very, very interesting and would provide just endless opportunities in the classroom that I would delight in.

CHAIRMAN KASS:  Thank you very much.

A child of immigrants appreciates the suspicion cast upon him of aristocratic sympathies, but that's all right.

Michael Sandel.

PROF. SANDEL:  Well, what I have to say has very much to do with what Bill has just pointed out, to do with the aristocratic flavor of the main argument of particularly the section on performance, superior performance.

And what I have to suggest is  not that that's misplaced or wrong-headed or misguided, the emphasis on excellence, but it does raise a question about how relevant the sports metaphor is to the wider society.

Now, there is a powerful intuition that there is something to the metaphor, something powerful to the metaphor of sports and a meritocratic (phonetic) society such as the one we live in, and I think part of what underlies that intuition is the sense that there is a ratcheting up of the pressures, and Bill spoke of pressures here, within the American meritocratic society, and that may be why parents are trying to enhance their children or athletes to enhance themselves.

There are the pressures there, and we also sense a ratcheting up of the competitive pressures in sports.  So there is a prima facie analogy.

But if the reason for our disquiet about sports enhancement, biotech sports enhancement, depends on this aristocratic or Greek picture of excellence, then the analogy has less force, might have less force for the kinds of enhancements that people are tempted to pursue to deal with the pressures of a meritocratic society for the following reason.

There are really two dimensions of sports that are at stake in performance enhancement.  One of them is the honorific dimension having to do with the way in which sports honors superior virtue and excellence, and the other is the competitive dimension which has to do with winning and losing, effectiveness.

Now, the argument here that tries to locate the moral crux of our disquiet in sports focuses almost entirely on the first, on the honorific, on the excellence.  That's the aristocratic; that's the concern with excellent display, the honorific dimension of sport.

But if it turns out that in a meritocratic society what leads people to strive for enhancements is not that they want honor and recognition, this Aristotelian virtue, but they want to get ahead.  They want their kids to get ahead.  They want their kids to get into the 92nd Street Y preschool.  They want their kids to get into Ivy League colleges.  They want their kids to be well-equipped.  They want for themselves to be able to compete effectively for jobs and under conditions where the pressures and the rewards and the stakes are more intense.

Then if that's what's animating the drive to enhancement  in the larger society, then to show that this honorific thing is at stake isn't going to be persuasive.  It's not going to be an apt metaphor because it takes that part of sports, the honorific rather than the competitive that's least relevant to the striving and the ratcheted up pressures that we see in contemporary meritocratic society.  That's about, you know, effectively getting admitted, getting hired, getting ahead, making a living, competing in a kind of ratcheted up thing that doesn't have to do with honorific dimensions at all.

So if you're right, and you may well be right, if you're right that this account of the dignity of human activity and so on and the analogies that come to mind are painting, dancing, building, designing, writing, singing, these all have to do with excellence, honor, recognition.

But that's not what's animating the drive to enhancement in a larger society, and so that may suggest that the analogy, the prima facie analogy between sports and meritocratic society breaks down if the reason for the disquiet is wholly cast in these aristocratic, Aristotelian, virtue-based terms.

CHAIRMAN KASS:  That's superb, Michael, and I think further rounds could reflect the power of that.  We have to add something.

And the sports, one is not uninterested in excellence.  I think everybody is, and Dan Foster's comments - I think it was Dan's comments - about how the people in the sports somehow don't want this, they could if they wanted to or if they were only interested in having people hit the ball farther.  Then they would legitimate these things. 

So there is some kind of concern for the, for lack of a better term, the genuineness of the excellence there even though it is a competitive activity and you might think that there would be reasons why the drive for competition and bringing more fans to the park, which is all to much on their minds anyhow and has led to certain other corruptions of the games, why they would overturn that.

But I think the kind of striving that you mentioned has to be dealt with in addition to the question of the concern for excellence as such.