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Normality and the Treatment-Enhancement Distinction

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Abstract

There is little debate regarding the acceptability of providing medical care to restore physical or mental health that has deteriorated below what is considered typical due to disease or disorder (i.e., providing “treatment”—for example, administering psychostimulant medication to sustain attention in the case of attention deficit disorder). When asked whether a healthy individual may undergo the same intervention for the purpose of enhancing their capacities (i.e., “enhancement”—for example, use of a psychostimulant as a “study drug”), people often express greater hesitation. Building on prior research in moral philosophy and cognitive science, in this work, we ask why people draw a moral distinction between treatment and enhancement. In two experiments, we provide evidence that the accessibility of health-related interventions determines their perceived descriptive or statistical normality (Experiment 1), and that gains in descriptive normality for such interventions weaken the moral distinction between treatment and enhancement (Experiment 2). In short, our findings suggest that the tendency to draw a moral distinction between treatment and enhancement is driven, in part, by assumptions about descriptive abnormality; and raise the possibility that normalizing novel biomedical interventions by promoting access could undermine people’s selective opposition toward enhancement, rendering it morally comparable to treatment.

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Data Availability

Supplementary data (data, materials and analysis scripts) are publicly availabe on the Open Science Framework at https://osf.io/8uwqk/.

References

  1. Hay, Mark. “In Istanbul, Drinking Coffee in Public Was Once Punishable by Death.” Atlas Obscura. Atlas Obscura, January 9, 2019. Retrieved from https://www.atlasobscura.com/articles/was-coffee-ever-illegal. Retrieved [last accessed 15 September 2022].

  2. Hopkins, Kate. “Banning of Coffee during Sultan Murat IV - Blame It on Starbucks !!” Dirassat, March 24, 2006. Retrieved from https://dirassat.posthaven.com/banning-of-coffee-during-sultan-murat-iv-blam [last accessed 15 September 2022].

  3. Crawford, John. 1852. History of Coffee. Journal of the Statistical Society of London 15 (1): 50–58. https://doi.org/10.2307/2338310.

    Article  Google Scholar 

  4. Coffee Rank. “World Coffee Consumption Statistics.”, November 1, 2020. Retrieved from https://coffee-rank.com/world-coffee-consumption-statistics/.

  5. Bear, Adam, and Joshua Knobe. 2017. Normality: Part Descriptive, Part Prescriptive. Cognition 167: 25–37. https://doi.org/10.1016/j.cognition.2016.10.024.

    Article  Google Scholar 

  6. Lindström, Björn., Simon Jangard, Ida Selbing, and Andreas Olsson. 2018. The Role of a ‘Common Is Moral’ Heuristic in the Stability and Change of Moral Norms. Journal of Experimental Psychology: General 147 (2): 228–242. https://doi.org/10.1037/xge0000365.

    Article  Google Scholar 

  7. Eriksson, Kimmo, Pontus Strimling, and Julie C. Coultas. 2015. Bidirectional Associations between Descriptive and Injunctive Norms. Organizational Behavior and Human Decision Processes 129: 59–69. https://doi.org/10.1016/j.obhdp.2014.09.011.

    Article  Google Scholar 

  8. Cialdini, Robert B., Raymond R. Reno, and Carl A. Kallgren. 1990. A Focus Theory of Normative Conduct: Recycling the Concept of Norms to Reduce Littering in Public Places. Journal of Personality and Social Psychology 58 (6): 1015–1026. https://doi.org/10.1037/0022-3514.58.6.1015.

    Article  Google Scholar 

  9. Bergquist, M., P. Blumenschein, P. Karinti, J. Köhler, É. Martins Silva Ramos, J. Rödström, and E. Ejelöv. “Replicating the Focus Theory of Normative Conduct as Tested by Cialdini Et Al. (1990).” Journal of Environmental Psychology 74 (2021): 101573. https://doi.org/10.1016/j.jenvp.2021.101573.

  10. Buchanan, Allen, Dan W. Brock, Norman Daniels, and Daniel Wikler. 2000. From Chance to Choice: Genetics and Justice. Cambridge: Cambridge University Press.

    Book  Google Scholar 

  11. Mehlman, Maxwell J., and Jeffrey R. Botkin. 1998. Access to the Genome. The Challenge to Equality. Washington, D.C.: Georgetown University Press.

  12. Parens, Erik. 1998. Special Supplement: Is Better Always Good? the Enhancement Project. The Hastings Center Report 28 (1): S1-17. https://doi.org/10.2307/3527981.

  13. Faber, Nadira S., Julian Savulescu, and Thomas Douglas. 2016. “Why Is Cognitive Enhancement Deemed Unacceptable? The Role of Fairness, Deservingness, and Hollow Achievements.” Frontiers in Psychology 7:232. https://doi.org/10.3389/fpsyg.2016.00232.

  14. Fitz, Nicholas S., Roland Nadler, Praveena Manogaran, Eugene W. Chong, and Peter B. Reiner. 2014. Public Attitudes toward Cognitive Enhancement. Neuroethics 7 (2): 173–188. https://doi.org/10.1007/s12152-013-9190-z.

    Article  Google Scholar 

  15. Koverola, Mika, Anton Kunnari, Marianna Drosinou, Jussi Palomäki, Ivar R. Hannikainen, Michaela Jirout Košová, Robin Kopecký, Jukka Sundvall, and Michael Laakasuo. 2022. Treatments Approved, Boosts Eschewed: Moral Limits of Neurotechnological Enhancement. Journal of Experimental Social Psychology 102: 104351. https://doi.org/10.1016/j.jesp.2022.104351.

    Article  Google Scholar 

  16. Mihailov, Emilian, Blanca Rodríguez López, Florian Cova, and Ivar R. Hannikainen. 2021. How Pills Undermine Skills: Moralization of Cognitive Enhancement and Causal Selection. Consciousness and Cognition 91:103120. https://doi.org/10.1016/j.concog.2021.103120.

  17. Funk, Cary. “U.S. Public Wary of Biomedical Technologies to 'Enhance' Human Abilities.” Pew Research Center Science & Society. Pew Research Center, August 20, 2020. Retrieved form https://www.pewresearch.org/science/2016/07/26/u-s-public-wary-of-biomedical-technologies-to-enhance-human-abilities/.

  18. Scheske, Christel, and Simone Schnall. 2012. The Ethics of ‘Smart Drugs’: Moral Judgments about Healthy People’s Use of Cognitive-Enhancing Drugs. Basic and Applied Social Psychology 34 (6): 508–515. https://doi.org/10.1080/01973533.2012.711692.

    Article  Google Scholar 

  19. Forlini, Cynthia, Jan Schildmann, Patrik Roser, Radim Beranek, and Jochen Vollmann. 2014. Knowledge, Experiences and Views of German University Students toward Neuroenhancement: An Empirical-Ethical Analysis. Neuroethics 8 (2): 83–92. https://doi.org/10.1007/s12152-014-9218-z.

    Article  Google Scholar 

  20. Ray, Keisha Shantel. 2016. Not Just ‘Study Drugs’ for the Rich: Stimulants as Moral Tools for Creating Opportunities for Socially Disadvantaged Students. The American Journal of Bioethics 16 (6): 29–38. https://doi.org/10.1080/15265161.2016.1170231.

    Article  Google Scholar 

  21. Giubilini, Alberto, and Francesca Minerva. 2019. Enhancing Equality. Journal of Medicine and Philosophy 44 (3): 335–354. https://doi.org/10.1093/jmp/jhz002.

    Article  Google Scholar 

  22. Cabrera, Laura Y., Nicholas S. Fitz, and Peter B. Reiner. 2014. Empirical Support for the Moral Salience of the Therapy-Enhancement Distinction in the Debate over Cognitive, Affective and Social Enhancement. Neuroethics 8 (3): 243–256. https://doi.org/10.1007/s12152-014-9223-2.

    Article  Google Scholar 

  23. Sabin, James E., and Norman Daniels. 1994. Determining ‘Medical Necessity’ in Mental Health Practice. The Hastings Center Report 24 (6): 5–13. https://doi.org/10.2307/3563458.

    Article  Google Scholar 

  24. Daniels, Norman. 2000. Normal Functioning and the Treatment-Enhancement Distinction. Cambridge Quarterly of Healthcare Ethics 9 (3): 309–322. https://doi.org/10.1017/s0963180100903037.

    Article  Google Scholar 

  25. Schwartz, Peter H. 2005. Defending the Distinction between Treatment and Enhancement. The American Journal of Bioethics 5 (3): 17–19. https://doi.org/10.1080/15265160591002755.

    Article  Google Scholar 

  26. Boorse, Christopher. 1975. On the Distinction between Disease and Illness. Philosophy & Public Affairs 5 (1): 49–68. http://www.jstor.org/stable/2265020.

  27. Boorse, Christopher. 1977. Health as a Theoretical Concept. Philosophy of Science 44 (4): 542–573. https://doi.org/10.1086/288768.

    Article  Google Scholar 

  28. Resnik, David B. 2000. The Moral Significance of the Therapy-Enhancement Distinction in Human Genetics. Cambridge Quarterly of Healthcare Ethics 9 (3): 365–377. https://doi.org/10.1017/s0963180100903086.

    Article  Google Scholar 

  29. Agar, Nicholas. 2010. Humanity’s End: Why We Should Reject Radical Enhancement. Cambridge, MA: MIT Press.

    Book  Google Scholar 

  30. Gyngell, Chris, and Michael J. Selgelid. 2016. Human Enhancement: Conceptual Clarity and Moral Significance. In The Ethics of Human Enhancement: Understanding the Debate, ed. S. Clarke, J. Savulescu, T. Coady, A. Giubilini, and S. Sanyal, 111–26. https://doi.org/10.1093/acprof:oso/9780198754855.003.0008.

  31. Rueda, Jon, Pablo García-Barranquero, and Francisco Lara. 2021. Doctor, Please Make Me Freer: Capabilities Enhancement as a Goal of Medicine. Medicine, Health Care and Philosophy 24 (3): 409–419. https://doi.org/10.1007/s11019-021-10016-5.

    Article  Google Scholar 

  32. Bostrom, Nick and Rebecca Roache. 2008. Ethical issues in human enhancement, in New Waves in Applied Ethics, ed. J Ryberg, T. S. Peterson, and C.Wolf (New York, NY: Plagrave Macmillan), 120-152.

  33. Savulescu, Julian, Anders Sandberg, and Guy Kahane. 2011. Enhancement and well-being. In Enhancing Human Capacities, ed. J. Savulescu, R. ter Meulen, and G. Kahane, 3–18. Oxford: Wiley-Blackwell.

  34. Earp, Brian D., Anders Sandberg, Guy Kahane, and Julian Savulescu. 2014. When Is Diminishment a Form of Enhancement? Rethinking the Enhancement Debate in Biomedical Ethics. Frontiers in Systems Neuroscience (8). https://doi.org/10.3389/fnsys.2014.00012.

  35. Zohny, Hazem. 2014. A Defence of the Welfarist Account of Enhancement. Performance Enhancement & Health 3 (3–4): 123–129. https://doi.org/10.1016/j.peh.2015.09.002.

    Article  Google Scholar 

  36. Repantis, Dimitris, Leonore Bovy, Kathrin Ohla, Simone Kühn, and Martin Dresler. 2020. Cognitive Enhancement Effects of Stimulants: A Randomized Controlled Trial Testing Methylphenidate, Modafinil, and Caffeine. Psychopharmacology (Berl) 238 (2): 441–451. https://doi.org/10.1007/s00213-020-05691-w.

    Article  Google Scholar 

  37. Allhoff, Fritz. 2005. Germ-Line Genetic Enhancement and Rawlsian Primary Goods. Kennedy Institute of Ethics Journal 15 (1): 39–56. https://doi.org/10.1353/ken.2005.0007.

    Article  Google Scholar 

  38. Jensen, Sean R., Saskia Nagel, Philip Brey, Tanne Ditzel, Rowena Rodrigues, Stearns Broadhead, and David Wright. “Sienna D3.1: State-of-the-Art Review: Human Enhancement.” Zenodo, March 29, 2018. https://zenodo.org/record/4066557.

  39. Daniels, Norman. 1988. Just Health Care. Cambridge: Cambridge University Press.

    Google Scholar 

  40. Davies, Madlen. 2022. Long Covid Patients Travel Abroad for Expensive and Experimental ‘Blood Washing.’ BMJ. https://doi.org/10.1136/bmj.o1671.

    Article  Google Scholar 

  41. Viciana, Hugo, Ivar R. Hannikainen, and David Rodríguez Arias. 2021. Absolutely Right and Relatively Good: Consequentialists See Bioethical Disagreement in a Relativist Light. AJOB Empirical Bioethics 12 (3): 190–205. https://doi.org/10.1080/23294515.2021.1907476.

    Article  Google Scholar 

  42. Kass, Leon R. 1998. The Wisdom of Repugnance: Why We Should Ban the Cloning of Humans. Valparaiso University Law Review 32 (2): 679–706.

    Google Scholar 

  43. Kass, Leon R. 2003. Ageless Bodies, Happy Souls: Biotechnology and the Pursuit of Perfection. The New Atlantis (1): 9–28. http://www.jstor.org/stable/43152849.

  44. Sandel, M.J. 2007. The case against perfection: Ethics in the age of genetic engineering, 2007. Harvard: Harvard University Press.

    Book  Google Scholar 

  45. Giubilini, Alberto. 2015. Don’t Mind the Gap: Intuitions, Emotions, and Reasons in the Enhancement Debate. Hastings Center Report 45 (5): 39–47. https://doi.org/10.1002/hast.458.

    Article  Google Scholar 

  46. Roache, Rebecca, and Steve Clarke. 2009. Bioconservatism, Bioliberalism, and the Wisdom of Reflecting on Repugnance. Monash Bioethics Review 28 (1): 1–21. https://doi.org/10.1007/bf03351306.

    Article  Google Scholar 

  47. Sparrow, Robert. 2011. A Not-So-New EUGENICS: Harris and Savulescu on Human Enhancement.” The Hastings Center Report 41 (1): 32–42. http://www.jstor.org/stable/41058988.

  48. Earp, Brian D., Jonathan Lewis, Vilius Dranseika, and Ivar R. Hannikainen. 2021. Experimental Philosophical Bioethics and Normative Inference. Theoretical Medicine and Bioethics 42 (3–4): 91–111. https://doi.org/10.1007/s11017-021-09546-z.

    Article  Google Scholar 

  49. Veit, Walter, Brian D. Earp, Nadira Faber, Nick Bostrom, Justin Caouette, Adriano Mannino, Lucius Caviola, Anders Sandberg, and Julian Savulescu. 2020. Recognizing the Diversity of Cognitive Enhancements. AJOB Neuroscience 11 (4): 250–253. https://doi.org/10.1080/21507740.2020.1830878.

    Article  Google Scholar 

  50. Awad, Edmond, Sohan Dsouza, Azim Shariff, Iyad Rahwan, and Jean-François. Bonnefon. 2020. Universals and Variations in Moral Decisions Made in 42 Countries by 70,000 Participants. Proceedings of the National Academy of Sciences 117 (5): 2332–2337. https://doi.org/10.1073/pnas.1911517117.

    Article  Google Scholar 

  51. Hannikainen, Ivar R., Edouard Machery, David Rose, Stephen Stich, Christopher Y. Olivola, Paulo Sousa, Florian Cova, et al. 2019. For Whom Does Determinism Undermine Moral Responsibility? Surveying the Conditions for Free Will across Cultures.” Frontiers in Psychology (10):2428. https://doi.org/10.3389/fpsyg.2019.02428.

  52. Selgelid, Michael J. 2014. Moderate Eugenics and Human Enhancement. Medicine, Health Care and Philosophy 17 (1): 3–12. https://doi.org/10.1007/s11019-013-9485-1.

    Article  Google Scholar 

  53. Veit, Walter. 2018. Cognitive Enhancement and the Threat of Inequality. Journal of Cognitive Enhancement 2 (4): 404–410. https://doi.org/10.1007/s41465-018-0108-x.

    Article  Google Scholar 

  54. Landy, Justin F., Daniel K. Walco, and Daniel M. Bartels. 2017. What’s Wrong with Using Steroids? Exploring Whether and Why People Oppose the Use of Performance Enhancing Drugs. Journal of Personality and Social Psychology 113 (3): 377–392. https://doi.org/10.1037/pspa0000089.

    Article  Google Scholar 

  55. Earp, Brian D., Joanna Demaree-Cotton, Michael Dunn, Vilius Dranseika, Jim A. Everett, Adam Feltz, Gail Geller, et al. 2020. Experimental Philosophical Bioethics. AJOB Empirical Bioethics 11 (1): 30–33. https://doi.org/10.1080/23294515.2020.1714792.

    Article  Google Scholar 

  56. Mihailov, Emilian, Ivar R. Hannikainen, and Brian D. Earp. 2021. Advancing Methods in Empirical Bioethics: Bioxphi Meets Digital Technologies. The American Journal of Bioethics 21 (6): 53–56. https://doi.org/10.1080/15265161.2021.1915417.

    Article  Google Scholar 

  57. Lewis, Jonathan, Joanna Demaree-Cotton, and Brian Earp. 2023. Bioethics, Experimental Approaches. In Encyclopedia of the Philosophy of Law and Social Philosophy, ed. M. Sellers and S. Kirste, 1–8. Dordrecht: Springer.

    Google Scholar 

  58. Tingley, Dustin, Teppei Yamamoto, Kentaro Hirose, Luke Keele, and Kosuke Imai. 2014. Mediation R Package for Causal Mediation Analysis. Journal of Statistical Software 59 (5): 1–38. https://doi.org/10.18637/jss.v059.i05.

    Article  Google Scholar 

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Acknowledgements

The authors have no competing interests to disclose. Participants provided informed consent prior to taking part in the studies. The studies were approved by the ethics committee at the University of Granada (3058/CEIH/2022) and were performed in accordance with the ethical standards put forth in the 1964 Declaration of Helsinki and its later amendments. Study data and materials, and analysis scripts are publicly available on the Open Science Framework at https://osf.io/8uwqk/. All authors contributed to the study concept and design. Study preparation, data collection, and statistical analyses were performed by DM under the supervision of IRH. The manuscript was drafted by DM and JR; BDE and IRH revised the manuscript. All authors read and approved the final manuscript.

Funding

This project was funded by a Grífols Research Grant in Bioethics of the Fundació Víctor Grífols i Lucas, and a grant from the Spanish Ministry of Science and Innovation (PID2020.119791RA.I00).

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Authors and Affiliations

  1. Department of Philosophy and Society, Universidad Complutense de Madrid, 28040, Madrid, Spain

    Daniel Martín

  2. Departamento de Filosofía I, Universidad de Granada, Granada, Spain

    Jon Rueda & Ivar R. Hannikainen

  3. Uehiro Centre for Practical Ethics and Experimental Bioethics (BioXPhi) Lab, University of Oxford, Oxford, UK

    Brian D. Earp

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Appendix

Appendix

Supplementary Analysis 1

To examine whether the effects of normality arose when looking separately at moral attitudes of individual behavior and community policy, we conducted further analyses with the three-item averages of moral attitudes toward individual behavior and policy: The normative distinction between treatment and enhancement arose both when evaluating an individual’s behavior (Exp. 1: B = 1.92; Exp. 2: B = 1.64), and a shift in community policy (Exp. 1: B = 1.67; Exp. 2: B = 1.25), all ps < 0.001.

In Model 3b (Experiment 1), normality was associated with approval of enhancement but not treatment. A further analysis with judgment scope as a third factor (scope: behavior, policy) revealed that the two-way interaction between normality and condition, F(1, 341) = 10.58, p = 0.001, was qualified by a three-way interaction with scope, F(1, 333) = 4.57, p = 0.033. The three-way interaction indicated that the association between normality and approval of enhancement was stronger for policy judgments than behavior judgments, B = 0.15, t = 1.99, p = 0.047 (whereas no such difference arose regarding treatment interventions, p = 0.30). Still, both simple slopes were statistically significant: Perceived normality was associated with approval of an individual’s use of enhancement interventions, B = 0.26, t = 3.67, as well as a policy advisor’s endorsement of enhancement interventions, B = 0.42, t = 6.04, both ps < 0.001.

In Model 5 (Experiment 2), normality causally affected approval of enhancement but not treatment. Entering judgment scope as a third factor revealed a two-way interaction between normality and condition, F(1, 490) = 8.17, p = 0.004, but no three-way interaction with scope, F(1, 492) = 0.22, p = 0.64. The effect of normality on approval of enhancement arose equally for judgments of an individual’s use, B = 1.11, t = 2.60, p = 0.009, and a policy advisor’s recommendation, B = 1.00, t = 2.35, p = 0.019.

Supplementary Analysis 2

We conducted mediation analyses (using the mediation R package; [58]) to assess whether perceived normality mediated the experimental effect of access on moral approval in each condition. In the enhancement condition, normality mediated the effect of access on moral approval (average causally mediated effect [ACME] = 0.58, p = 0.006)—whereas the direct effect was non-significant (average direct effect [ADE] = -0.08, p = 0.89). The corresponding analysis in the treatment condition uncovered no effects of access on moral approval of treatment—whether direct (ADE = 0.48, p = 0.31) or indirect via normality (ACME = 0.19, p = 0.22).

Supplementary Analysis 3

To assess whether the effect of normality on moral approval in Experiment 2 was non-linear, we replaced the discontinuous proportion of normality in Model 4 with the normality factor comprising three levels (low, intermediate, and high). We then conducted pairwise contrasts between levels of normality while applying Tukey correction for multiple comparisons: In the treatment condition, no significant differences arose between normality levels, ps > 0.40. Meanwhile, in the enhancement condition, moral approval differed between the low and intermediate levels of normality, B = 0.80, t = 3.01, p = 0.008, but not between the intermediate and high levels of normality, B = -0.00, t = -0.01, p = 1.

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Martín, D., Rueda, J., Earp, B.D. et al. Normality and the Treatment-Enhancement Distinction. Neuroethics 16, 13 (2023). https://doi.org/10.1007/s12152-023-09519-0

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