A therapy-enhancement distinction based on “absolute (im)permissibility”

In bioethics and public policy, a profound debate associated with genetic technologies is the moral differentiation between therapies (biomedical health-related procedures) and enhancements (non- or beyond-biomedical health-related procedures).Reference Resnik ¹ The past President’s Council on Bioethics, who comprehensively examined human biotechnology from this angle, states in their famous report “Beyond Therapy” that “those who introduced the therapy-enhancement distinction, hoped by [these] means to distinguish between the acceptable and the dubious or unacceptable uses of biomedical technology…” ² Many bioethics guidelines on genetic technologies today maintain this distinction wherein enhancements are deemed impermissible on the grounds that they extend beyond “health restoration,” whereas therapies are permissible because they are merely an extension of what is already (traditionally, inherently, naturally, etc.) deemed permissible: the restoration of health.

Let us observe a few of the notable policies and guidelines where this moral distinction is prominent. The Oviedo Convention, for example, only permits the carrying out of predictive genetic tests for medical purposes (article 12) and of genetic engineering for preventive, diagnostic or therapeutic reasons (article 13). ³ The International Bioethics Committee, who advises UNESCO, states that

The Nuffield Council on Bioethics similarly deems impermissible the use of genetic technologies such as non-invasive prenatal testing and whole genome/exome sequencing for non-medical reasons. ⁵ The American Medical Association’s Code of Medical Ethics states that

Finally, the ethical framework of the SIENNA project (Stakeholder-Informed Ethics for New technologies with high socio-economic and human rights impact), funded by the European Commission, holds that

This standard view on the therapy-enhancement distinction is similarly shared by the general public. In their study, Cabrera, Fitz and Reiner found that “irrespective of the domain to be enhanced [cognitive, affective, social], participants [in Canada and the United States] felt significantly more comfortable with therapy (improve capacities up to the norm) than with enhancement (improve capacities above the norm).”Reference Cabrera, Fitz and Reiner ⁸ In the UK, the Royal Society reports that 72% of people supported genomic editing to treat non-life threatening diseases, with even higher support for life-threatening ones, while 68% were against use for cosmetic reasons (e.g., changing eye/hair colour), and 60% against enhancing abilities. ⁹ The Pew Research Center found that, when the purpose is for treating serious diseases or conditions, 72% of those surveyed said that gene editing is an appropriate use of medical technology (whereas 27% said it would be “taking the technology too far”); and that, when the purpose is for enhancing “intelligence,” 80% said it would be taking the technology too far (whereas 19% said it was appropriate). ¹⁰ In a more recent survey, the Pew Research Center again reported that when “asked to consider the potential use of robotic exoskeletons, genetic modifications, and brain chip implants for a range of purposes, majorities of U.S. adults embrace these techniques when they would be aimed at helping people with physical, health or cognitive limitations.” ¹¹ Even though survey participants made distinctions between these three interventions with “enhancing” capacities, in each case, the majority expressed caution or uncertainty regarding their views; and only a maximum of 33% expressed that any one of these would be a “good idea for society.” ¹²

From “absolute (im)permissibility” to “conditional permissibility”

Even though the therapy-enhancement distinction has largely been based on “absolute-permissibility” terms, wherein therapies are seen as always permissible and enhancements as always impermissible, I argue that the distinction should not be understood in such a way. Moral reasoning quickly demonstrates that one cannot conclude that all enhancements are morally impermissible by claiming that restoring health is morally valuable. ¹³ For this, the argument would have to be that only health restoration is morally valuable. But this is clearly false; non-health related values such as ambition, friendship, personal growth, doing the right thing, a desire to better the world, autonomy, and justice are among the few other considerations that clearly have important moral worth. So, even when we assume (uncontroversially so) that pursuing health is permissible, it does not give us a convincing reason to find the pursuit of enhancement impermissible. This view is one that bioconservatives (e.g., past President’s Council on Bioethics), notable health justice theorists like Norman Daniels, and transhumanists (e.g., Humanity Plus) are all in agreement with.Reference Daniels ¹⁴

As Resnik correctly points out, the permissibility of an intervention depends on considerations such as the intent for its development and potential use, the likely consequences that will ensue, and whether any of these violate moral standards. ¹⁵ Observing the topic from another angle, Norman Daniels frames it like this:

This perspective entails that enhancements can be permissible if the “moral warning flags” are addressable without violating other moral limits and are subsequently addressed. What are some of these moral warning flags? According to the American Medical Association, these include enhancements’ potential for abuse and eugenic aim. ¹⁷ For many others including Schweikart, another warning flag is that “genome editing for enhancement can thwart social justice, as wealthy people will likely have greater ability to enhance their genome (and thus presumably certain physical and mental characteristics), furthering social and class divides.”Reference Schweikart ¹⁸

From a consideration of Resnik’s argument, however, we see that establishing an absolute moral distinction, if there is one, cannot rely on the inherent quality of enhancements as being “beyond health restoration.” But do the “moral warning flags” above fair any better in establishing a moral distinction on absolute grounds? Certainly not. We can imagine a variety of enhancements, such as interventions involving the aforementioned ethical virtues, as well as different preemptive social measures that can appease the moral warning flags and justify their permissibility, as Daniels’ point alludes to. Still, we can hold that even if there is no distinction on absolute grounds, there is, nonetheless, a difference between something being generally permissible (i.e., therapies) and something being conditionally permissible (i.e., enhancements). I will say more on this distinction below, but first consider the views of the opposite camp.

Apart from those who claim an absolute moral distinction regarding permissibility, there are also those who say there is, in fact, no moral distinction between therapies and enhancements. This camp’s reasoning is that both therapy and enhancement actually have the same aim. The value of “well-being,” for example, is generally provided as the motivating reason — and, many times, the actual outcome — for an individual who is in pursuit of a therapy. This group argues that “well-being” is similarly the motivating reason (and actual outcome) for an individual in pursuit of an enhancement. John Harris, for example, finds the moral value of both therapies and enhancements in their aim of reducing and preventing harms, and conferring benefits; and for Julian Savulescu, the “moral continuum” is based on the value of “leading a good life,” which both therapy and enhancement can accomplish.Reference Harris ¹⁹ For Savulescu, the value of “leading a good life” not only permits enhancements (and therapies) but also produces a moral obligation to enhance, when the enhancement is to advance an associated trait.Reference Savulescu ²⁰

The primary criticism that can be voiced regarding these arguments is that even if Resnik’s “good intention” criterion is met by a desire to “be well” or to “lead a good life,” a full moral analysis must still consider the consequences of the said intervention. Even if the person themselves ends up well, the intervention may still have negative consequences on others, leading to the possible conclusion that the enhancement is impermissible. But would this conclusion prove the critic’s position that there is an absolute moral distinction between therapies and enhancements? Harris and Savulescu are likely to respond in the negative, arguing that the same point regarding consequences can be said about therapies: imagine it was an evil person that was seeking therapy, and that they would continue to harm others once they were healthy enough.

Still, I do not agree with Savulescu’s position that there is a “moral obligation” to enhance because it is also a perfectly reasonable conception of “leading a good life” to place greater importance on remaining the way one is born. Sean Aas argues that persons living in a pluralistic society can have different reasonable interpretations of what “well-being” and a “good life” consists of, meaning that any one view of well-being or a good life cannot be said to necessarily outweigh another.Reference Aas, Cureton and Wasserman ²¹ In the context of genetic technologies, then, I argue that it is precisely because the pursuit of an enhancement can be a component of a reasonable understanding of well-being/good life that certain enhancements can be permissible. In other words, wanting to enhance is a position and a way of living that the state ought to prima facie allow a person to have and pursue. But importantly, I reach this conclusion on the basis of autonomy (its political conception), which gives weight to different interpretations of well-being/good life, without giving any special weight to any one of them. Hence, my argument is not dependent on a position that says there is a particular conception of how to live that is better than others; consequently, I argue that Savulescu’s conclusion should simply be that enhancements can be morally permissible. Remarkably, then, Savulescu can still maintain that there is a moral continuum by reminding us that therapies are similarly not absolutely morally permissible and that the most correct description of each is that they can both be morally permissible. So, by adding a condition (to enable a “good life”), Savulescu already makes his moral continuum argument conditional from the start since he would not deny that some enhancements can be used for evil.

There were some thought-provoking empirical findings in 2023 that, when substantiated further, could be coupled with the normative position that “enhancements can be morally permissible” to then influence policy direction on human technologies.Reference Martin ²² These findings hint that the reason for the public’s generally perceived moral distinction between therapies and enhancements may not actually be the result of thinking that enhancements are inherently (absolutely) unethical. Martin and colleagues conducted two experiments in which they found that the “accessibility of technologies” can play a determinative role in the perceived moral distinction, by affecting the technology’s perceived “normality.” ²³ In particular, they suggest that when accessibility to the said intervention is guaranteed and/or when it becomes otherwise “normalized,” the perceived moral distinction between treatment and enhancement can weaken. ²⁴ Another factor that can influence the normalization of enhancements is the perspectives of those who engage in gene editing. Though it is by no means a dominant view, Waltz and colleagues identified from their interviews of genome editing scientists and governance group members that one of the key positions (among three others) emerging from their qualitative study was the view that enhancements are not as morally problematic as suggested, with some highlighting the popularity and acceptance of cosmetic and plastic surgeries as comparison.Reference Waltz ²⁵ The 2022 study by the Pew Research Center described earlier also identified several factors that can influence the perception of the standard moral distinction. For example, they report that 59% of Americans say that brain chip implants would be more acceptable to them if they could turn their effects on and off; and 53% say that they would be more acceptable if implanting the device was non-surgical. ²⁶ These are suggestions that the moral judgements commonly made today — which closely track the standard moral therapy-enhancement distinction — are not immutable and may change with greater normalization, accessibility, ease of use, and user control, among other factors.

Yet, just like before, we can say that even if there is no distinction on absolute grounds and that enhancements can be morally permissible (and therapies impermissible), there is, nonetheless, a distinction between something being generally permissible (i.e., therapies) and something being conditionally permissible (i.e., enhancements). Therapies are generally permissible because the world is currently set up in a way where their potentially problematic uses are rendered mute by existing frameworks; and enhancements are conditionally permissible because the way society’s institutions are set up today are not generally sufficient to address potential moral warning flags. Although this is a descriptive, rather than normative statement, it carries moral significance for policy.

From “permissibility” to “desert”

Thus far I have argued that it is a political conception of autonomy, not a particular conception of “well-being,” “good life,” or “biomedical health” that generates the fundamental moral relationship between therapy and enhancement. The correct theoretical conclusions that can be drawn so far are that (1) policymakers should not categorically prohibit enhancements (on the supposed basis that enhancements are morally impermissible), not that an enhancement may not be prohibited (even if it is conducive to well-being); and that (2) generally, there is no moral obligation to enhance (even if it is conducive to well-being). The implication of this argument for a therapy-enhancement distinction is that therapy is generally morally permissible, and enhancement can be morally permissible.

Mamlqvist’s analysis of the problem is useful here in a way that furthers the debate. Malmqvist offers a criticism of the “moral continuum” argument, wherein he asserts that if therapies and enhancements were morally continuous, “health professionals and policy makers seem to have strong reason to attribute similar importance to them — that is, to inform people about them, encourage their use, allocate considerable resources to enhancement research and development, and so on.”Reference Malmqvist ²⁷ Then, without intending to generalize or provide a comprehensive justification of a therapy-enhancement distinction, Malmqvist offers a partial defense of it on the basis that “curing and preventing illness seems more likely than enhancements to benefit people in such ways [i.e., enable well-being/a good life].” ²⁸ This seems right, at least for the time being. But the important point is that this difference has directly to do with “justice,” at the level of what is owed to persons by the state, not directly or only with “permissibility” (absolute or conditional) at the level of individual use. Spelled out, the moral difference-maker arising from the “likelihood to benefit” point is that enhancements we deem permissible need not be provided by the state (at least for the time being). So what we should mean when we say there is a moral therapy-enhancement distinction ought to incorporate the idea that therapy is, generally speaking, not only morally permissible but also owed to individuals (due to its descriptively large benefits arising from enabling participation in social cooperation and competition, for example) whereas, at this stage, enhancements may only be morally permissible (based on the satisfaction of certain moral conditions), but not provided/funded.

The stability of this moral distinction

Recognize that the distinction I propose stems from starting with an independent premise of “public reason autonomy,” which is then applied to traditional therapies and enhancements (in a societal context in which problems that may arise from therapies, but not enhancements, are easily controllable) to say: therapies are generally permissible and owed, and enhancements only conditionally permissible, acknowledging that we need additional contextual information before deciding whether a given intervention is indeed permissible. On the other hand, the traditional understanding of the moral distinction is quite decisive, equating therapy with moral permissibility and enhancement with moral impermissibility. Although it is not morally defensible, sometimes decisiveness could be a policy advantage. Yet, when it comes to using the traditional distinction, we see that it struggles when real life cases do not fit so neatly; it scrambles to redefine an intervention as “therapy” if it appears morally defensible, or as enhancement if it seems morally problematic. ²⁹ My conceptualization sidesteps that forced labeling, viewing “therapy” and “enhancement” as gaining a definitive status with more information. In this way, cases, including borderline cases are handled more coherently, though with less independent decisiveness — a problem we will revisit later. Let us now observe some of its advantages further, starting with how my conceptualization of the moral distinction deals with enhancement in specialized contexts.

Enhancements in military and space exploration

There are various areas of specialized human activity such as military operations and space exploration where enhancements appear to be unproblematic. Szocik and Reiss explore bioethical challenges in such contexts — involving wearables, biomaterials, genetic procedures for self-healing or preventing injuries — and, without needing to call for a novel ethical framework, admit that enhancements in these contexts generally attain a different status: they seem permissible due to their critical role in sustaining such efforts.Reference Szocik and Reiss ³⁰ Notably, these considerations are not merely hypotheticals but active questions that real-world institutions are currently dealing with.Reference Scott ³¹ Recently, NATO released its biotechnology and human enhancement technologies strategy (public version), and the Translational Research Institute for Space Health (TRISH) published its strategic plan for 2025–2028. ³² In its plan, TRISH underlines the importance of advancing scientific and technological research to prepare and “thrive” in deep space. ³³ Both NATO and TRISH state in their respective strategic plans that their desired outcomes include developing “robust pathways to operationalise Principles of Responsible Use for BHE [Biotechnology and Human Enhancement Technologies] in defence and security;” and seeking “operational insights and guiding principles that preserve human health and performance in space,” respectively. ³⁴

The relevant question for us now is whether the apparent general permissibility of enhancements in contexts like national defense and space exploration challenges my moral categorization of enhancements as merely conditionally permissible. At first glance, there does appear to be a conflict, suggesting that it might not be applicable or that it is not useful in these contexts. However, it need not pose a problem if we take up the question from the correct angle and recognize that a specialized setting can supply precisely those moral conditions — such as an important collective purpose and a well-regulated protocol — that satisfy the requirement for permissibility in that setting. Far from weakening my conceptualization of the therapy-enhancement distinction, this flexibility is a feature and advantage of it. ³⁵

Different kinds of enhancements

Now I ask whether my categorization of enhancements as “conditionally permissible” will seamlessly apply for different kinds of enhancements. We know from earlier discussions that if the effects of an enhancement cannot be contained to the consenting individual, it may impose burdens that undermine others’ autonomy, which is a strong basis for deeming the enhancement impermissible. Consider a neural implant that significantly enhances cognitive capacity but meets one or more of the following conditions: (1) it is not universally desired, (2) it is prohibitively expensive for many who might want it, and/or (3) those who decline or cannot access it cannot be reasonably protected or accommodated. The resulting inequalities from such scenarios provide compelling reasons to judge the enhancement as impermissible. What is important about these judgements, however, is that they could apply to all kinds of enhancements, not just genetic or neural ones. After all, we know that all else being the same and morally (un)problematic, the process alone cannot make a moral difference. But sometimes all else is not the same.

The question, then, is whether certain kinds of enhancements — such as germline, pharmaceutical, surgical, neural, or robotic — introduce unique challenges that, by their very nature or consequences, make them clearly “permissible,” “impermissible,” or “owed.” ³⁶ In her work on neuroethics, Goering provides three characteristics that appear more or less in different kinds of enhancement in a way that could allow us to track their normative standing.Reference Goering, Johnson and Rommelfanger ³⁷ These are the level of precision (effectiveness, short term effects); invasiveness; and long-term effects (irreversibility, unpredictability, etc.). I find the third — an intervention’s long-term effects — useful for my purposes here because it is already apparent (and unproblematic) that any intervention must demonstrate safety and effectiveness and have the full informed consent of the person. But the unpredictability and risks associated with long-term outcomes do say something significant about the normative status of a kind of enhancement that has this feature. At the present, germline editing exemplifies this concern; its potential for unforeseen and problematic long-term consequences provides a compelling reason for its impermissibility.Reference Baltimore ³⁸ But let us recognize that, here too, the conclusion coheres with my conceptualization of enhancements because those features that make germline editing problematic now are not intrinsic features of it. It is a reasonable expectation that, with time, the long-term predictability and riskiness of germline editing could be appeased through a combination of advancements such as greater information, societal understanding, acceptance, desire, and preparation. And so, once again, we will be left with the kinds of considerations that this discussion began with: what are the intents, effects on others, broad consequences, possible responses, etc. — all considerations that fit my moral categorization of enhancements as being conditionally permissible. ³⁹

The practical value of this moral distinction

From the consideration of specialized contexts and various kinds of enhancements, it becomes clear that the categorization of enhancements — as potentially permissible but not presently owed — demonstrates both flexibility and coherence. This adaptability is a theoretical strength. At this point, a critic might acknowledge that the framework aligns well with our considered moral judgments about enhancements, sidestepping the “forced labelling” problem of the traditional distinction.Reference Freedman ⁴⁰ Nevertheless, they could argue that it still falls short as a policy tool, offering little practical guidance for actually determining which enhancements are permissible, impermissible, or possibly owed. To the extent that any decisive ruling on enhancements still requires an assessment of intentions, consequences, and context-specific factors, the critic could claim it is merely academic to try to formulate such discussions in terms of any kind of therapy-enhancement distinction. Thus, we are back at the potential “independent decisiveness” problem.

A response to this challenge comes from thinkers like Daniels and McGee, who assert that we should not demand too much from a therapy-enhancement distinction.Reference Daniels ⁴¹ In line with this thought, in the remainder of the paper I will argue that if understood and used properly, the moral distinction I favor does have valuable policy functions, even if it is not “independently decisive.” Primarily, what should be noted is that by trading “independent decisiveness” with “appropriateness,” my moral categorizations demonstrate a strength, not a flaw, particularly because we are addressing a policy topic that is full of moral ambiguity and ambivalence. Even principles explicitly designed to classify actions as right or wrong cannot do so very easily or in isolation, whether it is at the theoretical level (why accept deontology over utilitarianism, for example) or the applied level (a policy might be good in some sense but still wrong to implement). It is a feature of moral reasoning and public policy itself that we will need contextual information to make decisive choices.Reference Regan and Moore ⁴² For example, any question regarding permissibility will have to address questions such as the following:

• ▪ How will the availability of the intervention be perceived by persons?

• ▪ How will it impact familial, commercial and other societal relations?

• ▪ Are there likely to be problematic expectations or pressures to use them?

• ▪ Will it negatively impact equality of opportunity provisions?

• ▪ Will non-users be perceived as “second-class”?

• ▪ Will it create permanent gaps between initial users and those who only have access at a later time? Can it be subsidized to increase access without creating pressure for others to use it?

Incorporating and accounting for all the factors relevant to making the correct decisive choices are too numerous and too complex to be accurately captured by a therapy-enhancement distinction. Notwithstanding, the point is that it is not really a significant concern if a policy tool is not independently decisive on questions of permissibility. If a policy tool has other useful functions for dealing with issues emerging from therapies, enhancements and their real or perceived moral differences, these features could be sufficient for retaining a therapy-enhancement distinction. I argue that my therapy-enhancement distinction does have such useful features.

Starting with the obvious, my distinction is “guiding” because it identifies sensible moral categories (that are not strictly black or white), and as such, the framework inherently invites (through the claim of “may be permissible”) further refinement of the conditions under which enhancements might be deemed permissible in society. It has a backward-looking role as well. If it is determined, after a full ethical assessment, that we have good reasons for why a particular enhancement is unproblematic in our society, then the fact that there is a general category to which the enhancement belongs to, and that the general category it belongs to is able to high-level explain (or was able to predict) that this was a possibility, then this state of-affairs would be demonstrative of a high-level legitimizing or anticipatory role. Knowing that society is already structured to handle any potential societal harms arising from therapies suggests to us that fewer resources are likely to be needed to police those interventions; it will tell us the focus regarding therapies, rather, is in ensuring their availability and accessibility. At the same time, the distinction informs us that an enhancement is more likely to result in problematic (yet solvable) outcomes, signaling that more vigilance is warranted for enhancements.

But that is not all, remember. Another way in which the distinction has a valuable function for policy, I argued, is through the distinction from justice more broadly, which is that therapies are owed to individuals, whereas, at this stage, enhancements may only be morally permissible and not owed to individuals. This signals that the priority for the state at the present moment is clearly on the provision of therapies to its citizens. Of course, this distinction from justice is not indicative of the idea that no resources can or should be allocated for enhancement-related activities (e.g., research and/or societal modifications that would render certain enhancements permissible) but I leave details of this discussion for another paper.