The Case Against Perfection: Ethics in the Age of Genetic Engineering by Michael J. Sandel (Belknap Press, 162 pages, $18.95)
Most religious traditions today not only accept advances in medical science but regard them in some sense as a moral imperative. Christians say, "God helps those who help themselves," Jews are urged to "repair the world" (and even to complete the work of creation), and the Dalai Lama famously reveres science and expresses doubts about elements in his own great religious tradition when they seem to conflict with science's findings.
This was not always the case. Medieval Catholic clerics warned that medical treatment betrayed a lack of faith and deemed it incompatible with holy orders. Edward Jenner's invention of inoculation, in the 1790s, met with wide religious condemnation on both sides of the Atlantic on the grounds that inoculation usurped God's power over life and death, and that only hypocrites could accept it and still pray. The 19th-century Scottish Calvinist church reviled the use of chloroform to assuage the pain of childbirth as a "Satanic invention" that subverted God's design.
Like Prometheus, Jenner gave humanity a new kind of power -- and, for most of history, the Christian God could apparently be offended just as Zeus could. But today only a few medical Luddites think Jenner burns in hell; most believers think of him and other medical scientists as God's assistant healers, something like the residents in a surgical suite handing the senior surgeon instruments and closing up after the serious work is done.
Still, this history, in which right-thinking clergy deemed the greatest advances in medicine the greatest affronts to God, is instructive. Then, as now, some scientists were "playing God," egregiously trying to control life and death, to tinker with birth, pain, and suffering -- God's business, if anything is -- and thereby undermining not just faith but the order of the world.
Many argue that today is different, and in some ways it is. Control of biological processes is greater than ever, and will be greater still. In many species, genes can be knocked out and socked in, and a growing Noah's ark of animals can be cloned. Cells can be sucked from early embryos and, perhaps, turned into engines of organ repair. Few mothers need to ask, "Is it a boy or a girl?" in the delivery room, as prenatal knowledge becomes universal and deliberate opting for one or the other sex becomes more common. Sperm banks give women or couples control over countless characteristics of their not-yet-conceived unborn offspring, and, through in-vitro fertilization, choice is possible even when the egg and sperm are your own. Growth hormone makes short children taller whether or not they have a deficiency, and eventually an inserted gene will boost their own supply.
Surely a God with the power to make even kings tremble must be glaring down on all of this, thinking enough is enough. Or at least there must be a troubled inner voice raising some fundamental moral questions. Michael Sandel certainly hears that voice. A Harvard political philosopher and former member of President Bush's Council on Bioethics, he has written a book of reflections -- a meditative essay, really -- on the moral questions raised by these new technologies, among others. In general, he is uncomfortable with the technologies and, like the members of the president's council, he holds firm opinions against them. I find neither his arguments nor theirs persuasive.
Despite the subtitle -- Ethics in the Age of Genetic Engineering -- much of The Case Against Perfection goes beyond genetics. A sports enthusiast, Sandel asks if extraneous enhancements -- whether steroids or genes -- are in the spirit of the game. Aren't we looking for truly human competition, human excellence? Don't the medical adulterations take that away?
Perhaps, and certainly the arbiters of the games are trying to keep bio-finagling at bay. But Sandel himself observes that shoes were once thought adulterants of the skills of track and field. Do we think that the millions who pay good money to watch Barry Bonds slug away at 98-mile-an-hour pitches are fools to do so because of the steroid scandal? Or do they just not care as much as bioethicists think they should?
When I watch basketball giants jumping to score points from an 11-foot height, knowing that the tallest men of the past reached perhaps 6 feet, am I watching human or superhuman players? When I consider that the best football players of 1920 could not survive on a modern gridiron, do I think that scientific methods of coaching, selection, nutrition, and exercise have violated the essence of the sport? Drugs are different, but, having no crystal ball nor being able to read the minds of hundreds of millions of sports fans, I don't know whether steroids will be successfully forbidden. Time and sports fans will tell. Perhaps one day there will be parallel halls of fame for "enhanced" and "naked" versions of the games.
We see the phrase "gene manipulation" and think we are in a Frankensteinian realm that has never existed before. In a technical sense that is so. But more fundamentally, there is no intrinsic difference between inserting genes and inserting steroids -- steroids work by turning genes on anyway -- as long as the inserted genes are targeting muscle and bone, not eggs and sperm. The manipulation of genes in muscle and bone is a form of medication, legitimate or otherwise. Yes, there is a new technical principle involved, but it's still basically medication.
Growth hormone works well, and it could conceivably raise the ante of height in basketball if an eager sports-minded parent of a 6-foot-tall middle-school player gets his or her hands on it. But should the coach turn away a talented kid because his father got him growth-hormone injections? Or will the alumni still pay to see the slam dunk?
What else should moral philosophers condemn? How about the nose job a beautiful friend of mine had as a teenager, which has made her feel a little phony ever since? How about the breast reduction one of my daughter's friends had recently because she was both embarrassed by the size of her chest and limited in athletics and dance? How about the people I know on Wellbutrin? Viagra?
Philosophy is a noble and heartfelt exercise, but life is life, and people enhance it -- always have, always will. What it really comes down to in the end is personal choice. Do I think that should be limitless? No. But I am glad that when my daughter's friend talked with her parents and her doctor about her breasts, no philosophers showed up. If they were freely consulted, fine -- but otherwise it's none of their business.
Now we come to something harder. Germ-line therapy -- tweaking genes in eggs and sperm -- is different because those genes are forever. If you give me a gene as a teenager to bulk up my biceps, my kids may still be born weaklings. Tweak my sperm, and my babies will likely have big biceps, as will their babies, and theirs. This is a eugenics that eugenicists never dreamed of.
We have a version of it already. We can identify many genes we consider bad -- for Tay-Sachs disease, say, or cystic fibrosis -- and abort the fetuses, or select away the embryos during in-vitro fertilization. Even anti-abortion ethicists seem to have little trouble with the latter tactic. Few would shed any tears if Tay-Sachs, which horribly destroys the brain and kills before age 2, were never seen again. But consider bipolar and other mood disorders: Sufferers and their relatives tend to be more creative than average. If we eliminated bipolar genes, what else would we eliminate? The line between illness and variety is not always neatly drawn.
Sandel, like the bioethics council on which he served, takes a dim view of any form of enhancement. He casts a jaundiced eye on parents who put their kids in certain kindergartens to prime them for Princeton and Harvard, and on the notion of "a Viagra for the brain." I might think those parents foolish, but it's their kid and their money. And if a brain enhancer existed, at 60 I would go to the ends of the earth to get it.
One form of "genetic" enhancement especially irksome to Sandel is choosing eggs or sperm on the basis of the health, brains, and beauty of the donors. But this practice is little more than a technological extension of mate choice. Those who can have always chosen their mates -- and therefore eggs or sperm -- using the same criteria. Technology makes it different, but why not extend access to desirable qualities to those who, in the context of natural mate choice (discrimination in both senses of the word), cannot get them?
We can't assume we know in advance the consequences of our newfound reproductive freedom. A sperm-sorting company helps prospective parents bias their chances for a boy or a girl; most customers want girls. And Sandel opens his book with the case of a deaf couple who wanted a deaf child and found a sperm donor with hereditary deafness. As the hearing child of deaf parents, I was saddened by the story, but I don't see it as very different morally from a deaf woman choosing that same man as her husband. Sandel opens the book with this case, apparently to shock us; in my view, however, all it does is highlight the fact that individual human beings make individual choices.
Sandel, like most who oppose enhancement, improperly invokes the eugenics of the early 20th century (and even that of Hitler) to bolster his argument. But as he himself points out, the new technologies dwell in a completely different moral universe. A state-run, mandatory program of sterilization to cull the "unfit" against their will has nothing whatever to do with offering individuals options. After our last benighted century, few of us could countenance eugenics-by-mandate.
Reproductive technologies, however, are not about state coercion but about the opposite; the question is not whether the government will force them on me but whether the government, advised by Sandel and the Council on Bioethics, will step between me and my doctor and stop me from using them. Sandel's counter-arguments -- that compulsory use of genetic engineering could emerge someday, or that currents in the culture will exert a kind of coercion -- are completely unconvincing. If he doesn't like the culture's idea of beauty or intelligence, let him change the culture. To his credit, he points out that moral philosophers as different as John Rawls, Robert Nozick, and Ronald Dworkin accept forms of genetic enhancement.
Gender selection in India is indeed worrisome: The proportion of females there is dropping precipitously, and the consequences a generation from now could be dire. But sex selection per se (as opposed to one of its methods, abortion) is a political-economic matter, not an ethical one. And as the great evolutionary theorist Ronald A. Fisher showed, skewed sex ratios right themselves as competition for the scarcer sex intensifies. In humans this will likely happen faster, as many parents who choose sons realize that they will have no grandchildren.
In an epilogue, Sandel briefly treats a truly ethical issue: the status of the fetus. If killing a fetus -- whether for personal or research purposes -- is killing a person, it is obviously wrong, and both state and church can intervene. The trouble is that we differ about whether a fetus is a person. President Bush and the council that serves at his pleasure are heavily biased on this issue against both abortion and stem-cell research, but the majority of the country, as represented in polls and in Congress, has the opposite view. As Sandel points out, people who accord the fetus personhood are inconsistent: If destroying embryos is murder, embryonic wastage must be death. Where are the sacraments and the grieving for late menstrual periods, a large proportion of which contain early embryos?
Sandel favors embryonic stem-cell research. But in any case, now as in the past, religious opposition will not retard legitimate science very much. California and other states, private corporations, and many nations are pressing ahead with this research -- a consensus that perhaps should inform our ethics -- and the main long-term effect of Bush's ban will be to export a few future Nobel Prizes.
Sandel wants us to be open to "the unbidden." But the unbidden used to include smallpox and crushing childbirth pain, and it still includes horrific genetic diseases. A line needs to be drawn somewhere between discarding a Tay-Sachs embryo and doing the same with one that will probably develop dementia at the end of a long, rewarding life. Philosophers make their most useful contribution when they clarify thought and language, and though Sandel does help clarify some of the issues, his book is replete with unconvincing moral judgments, much like the bioethics that is grounded in theology.
People use SAT prep courses and orthodontics to level the playing field for their children by eliminating irrelevant obstacles. We increasingly see Ritalin and Wellbutrin in a similar light, and we may go on to think the same of growth hormone. I see no intrinsic reason why gene therapy outside the germ line should be different. There will be errors, like the big one we made with estrogen replacement, but they will be scientific errors, not ethical ones, and they will have scientific remedies.
As for our new and expanding suite of reproductive choices, many deem them a declaration of independence from evolution's caprices. If openness to "the unbidden" means the reproductive roulette that gave us Tay-Sachs, good riddance to it; I won't miss it one little bit. As for trying to eliminate stupidity and ugliness, it's fine for nice-looking intellectuals to tsk-tsk others, but if some want to give their children and grandchildren a different future, I won't be standing in their way.
Are there hard choices ahead? Certainly. People must be taught the science, as in any genetic counseling. Eliminate the genes for sickle-cell anemia and you will decrease future generations' resistance to malaria. Eliminate those for bipolar disorder and you will find future generations less creative. Choose boys too often and you will increase crime and forgo grandchildren. These are in one sense ethical issues. We used antibiotics thoughtlessly with unfortunate results. The ethical path is not to stop using them but to use them more judiciously.
There is one overarching ethical issue to which Sandel gives short shrift: inequality of access. He puts it aside because he wants to develop general moral rules for the procedures themselves. But the weightiest moral problem in the quest for perfection is that, at least under present circumstances, it increases inequality. Evolution itself is unfair enough without giving the fittest a technological boost. So there is a world of difference between a restricted quest for perfection and one open to everyone.
"[C]hanging our nature to fit the world," Sandel concludes, "deadens the impulse to social and political improvement. Rather than employ our new genetic powers to straighten the crooked timber of humanity,' we should do what we can to create social and political arrangements more hospitable to the gifts and limitations of imperfect human beings." Can't we walk and chew gum at the same time? I testified at a Senate hearing in favor of universal health care at the same time that I was paying to straighten my daughter's teeth.
"The crooked timber of humanity" means different things to different people, and we will be talking for generations, if not centuries, about how and how much to try to straighten it. But bioethicists should get off their high horses. Sandel is entitled to his opinions, but he is not entitled to mine. I have to ask myself not just how much perfection to seek but whether I want to live in a world where theologians and philosophers tell me how much I can have.
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