At the risk of putting words in Pellegrino's mouth (and readers can judge for themselves whether my interpretations of his article are fair), his central thesis seems to be that healing, or therapy, as he calls it, is an acceptable end of medicine, while enhancement, for the most part, is not. The fundamental problem with this thesis, however, is Pellegrino's inability to provide any concrete distinction between the two. The reader knows that Pellegrino deems some sorts of enhancement wrong, but Pellegrino himself generally refuses to say with much specificity which sorts are wrong; furthermore, where he is willing to say that certain practices are "not morally permissible," he fails to provide any argument to back up the claim.
In fairness to Pellegrino, he acknowledges the difficulty of distinguishing between healing and enhancement almost immediately: "Almost every present-day commentator underscores the difficulties, impossibility, or futility of any definition that seeks to distinguish enhancement from therapy." Nonetheless, Pellegrino then sets out, albeit somewhat halfheartedly and certainly unsuccessfully, to draw such a distinction and moralize accordingly.
"In this essay," he declares, "my operating definition of enhancement will be grounded in its general etymological meaning — i.e., to increase, intensify, raise up, exalt, heighten, or magnify. Each of these terms carries the connotation of going 'beyond' what exists at some moment, whether it is a certain state of affairs, a bodily function or trait, or a general limitation built into human nature...For this discussion, enhancement will signify an intervention that goes beyond the ends of medicine as they traditionally have been held."
Almost immediately, then, Pellegrino raises questions of semantics that he never really answers. What does it mean, for example, to go beyond "a general limitation built into human nature"? Would using contact lenses to give a nearsighted person 20/20 vision constitute enhancement? After all, one could certainly argue that poor sight is a "limitation built into human nature," and indeed, a health article hosted on Yahoo.com states that "nearsightedness is usually a variation from normal, not a disease." So if poor vision is "normal" and "not a disease," doesn't it follow from Pellegrino's definition that contact lenses are an enhancement and not a therapy? And yet, I strongly suspect that Pellegrino himself would not say that the use of contact lenses is in any way immoral, and if he did, it's obvious that the vast majority of people would disagree with him.
But then, I should note that Pellegrino admits he does not consider all enhancement bad. For one thing, even though Pellegrino seems keen to criticize those "physicians [who] have already crossed the divide between treatment and enhancement, between medically indicated use and patient-desired abuse," he goes on to concede that even "valid" therapies will result in enhancement of a sort: "There is no question that the cure or amelioration of a disease process will also result secondarily in enhancement of the patient's life." Apparently, though, that kind of enhancement is acceptable because it comes "secondarily" to the "primary intention" of treating disease.
So, just to clarify (or try to): Pellegrino is against those doctors who have "crossed the divide between treatment and enhancement," except that he doesn't mind "enhancement" that "result[s] secondarily" from treatment. Confused? Wait, it gets worse.
A few paragraphs later, Pellegrino informs us that "the motives, ends, and means of enhancement as a primary intention are morally variable. Some ends — like the desire for healthy, bright, and lovable children — are understandable. If the means that bring these states about do not themselves dehumanize their subjects, they might be within the legitimate ends of medicine, particularly preventative medicine."
Alas, the good doctor fails to tell us with any specificity exactly what kinds of enhancements "might" be "legitimate" and "understandable." Although he has already implicitly impugned the morality of those physicians who have "crossed the divide between treatment and enhancement" and committed "abuse," he seems utterly incapable of saying just where that moral divide lies. Instead, we are treated to numerous caveats and qualifications about enhancements that "might" be "understandable," but only "if" they "do not dehumanize" anyone.
It almost seems as if Pellegrino is trying to hedge his bets. Perhaps mindful of biotechnological advances, such as in vitro fertilization, that were once highly controversial but are now far more widely accepted, he seems, for the most part, unwilling to single out a specific type of procedure or enhancement for censure, knowing, as he must, that what seems shocking today may seem quotidian tomorrow. Morality is a moving target, a fact which Pellegrino seems to acknowledge in his muddled, perhaps purposefully vague, attempts to define just what is and isn't good medicine.
Which is not to say that Pellegrino is completely unwilling to make some jaw-droppingly sententious declarations: "Procedures...derived from the destruction of human embryos, distortions and bypassing of normal reproductive processes, or cloning of human beings, etc., are not morally permissible no matter how useful they might be therapeutically."
Oh, really? Last I heard, there was a fairly robust political debate going on in this country about whether embryonic stem cell research, which involves "the destruction of human embryos," is morally acceptable, with the majority of Americans seeing things quite differently than Dr. Pellegrino. Meanwhile, we can assume from this quote that he views abortion as morally repugnant, but that doesn't change the fact that the procedure is currently legal under federal law. As for the aforementioned in vitro fertilization, one gets the impression from this statement that Pellegrino would condemn that as well — because it entails the "bypassing of normal reproductive processes" — but again, public opinion would be against him on that score. One can only wonder how Pellegrino feels about condoms.
In short, whatever Pellegrino's personal opinions, it appears that morality is more relative than he might like it to be. His piece, then, is rendered feckless not only by his own inability to "distinguish enhancement from therapy" in any meaningful way but also by the more fundamental fact that what Edmund Pellegrino, or anyone else, sees as "not morally permissible" might seem perfectly permissible, even virtuous, in the eyes of someone else. Morality, like beauty, is in the eye of the beholder.
To be sure, there are certain things that the vast majority of people would describe as immoral enhancements. Most people, for example, seem to be against the use of steroids to increase athletic prowess. That said, there are many other enhancements that a majority of people might be against now that majorities will approve of in the future, and even steroid use for athletics might become more acceptable as time passes.
As noted above, Pellegrino seems to be aware of this protean aspect of morality and to even be resigned to the fact that less conservative impulses than his own will eventually win out. Indeed, for the last seven paragraphs of his article, he writes as if the future proliferation of biotechnological enhancements were already a fait accompli. We are told that there will be "a cascade of demand" for enhancements, that "a willing and paying clientele is certain to develop."
To some extent, then, in these closing paragraphs Pellegrino seems to acknowledge that his arguments are moot, and in the long run, on this score at least, I suspect he will be proven right. That said, the opinions of Pellegrino and like-minded individuals do have considerable effect in the short term.
Pellegrino himself is currently the chairman of the Bush administration's President's Council on Bioethics, so of course he holds considerable sway in certain contemporary debates. Those wondering, for example, how Bush would justify his veto of a stem cell research bill passed by Congress and approved of by a majority of Americans would do well to consider Pellegrino's writings. In the end, of course, a stem cell funding bill will presumably be passed — most probably under Bush's successor — but in the meantime there are many who would argue that the United States has wasted years of potential research that might have led to more quickly finding cures for a number of devastating diseases. In some corners, however, it may be that political expediency — in this case, "playing to the base" — is a higher priority than medical expediency.
My qualms with Pellegrino's piece notwithstanding, I would caution the reader not to misunderstand me. I am not suggesting that just because a clear line between therapy and enhancement does not exist and that because morals are relative that the doors be thrown open to all kinds of therapeutic experimentation. I am primarily pointing out that Pellegrino's article and similar ones are of little use in determining what should and should not be allowed.
Ultimately, however, I do think that Pellegrino unwittingly suggests, in what is meant to be a warning of the "horrors" to come, a basic guideline by which we might navigate the brave new world of biotechnological enhancements: "The modern and post-modern emphasis will be on effective regulatory measures, better techniques, and competent practitioners...Restraint or prohibition beyond prevention of abuses and harmful side effects is highly unlikely. Those who restrict freedom of choice will be seen as a danger to the realization of a higher quality of life for all."
Right. And what, exactly, is wrong with any of that?
