ENHANCEMENT MEDICINE

Before medical treatment there is preventative medicine; beyond treatment there is enhancement. This means that health, namely that state which, as Gadamer would say, is “in itself natural” is no longer sufficient, ait is necessary to go “beyond”. But in which direction? Toward what idea of health and, above all, toward what idea of man and society? In other words – and here I come to the specific question I would like to consider – what consequences might new biotechnological developments have on the public domain?

First of all, a few words about the concept of health.

Among the many effects of modern differentiation and secularization we may certainly include the gradual rise of health among the highest values. While the Latin word “salus” implied physical health (bodily health) as well as spiritual health (in other words, salvation), today the two meanings have become separated to the point of being almost extraneous. All of this, as it is ease to see, has been especially harmful to spiritual health. But if we consider the matter more carefully – as we are bound to do – this is in danger of harming the wellbeing of all mankind, which, for the simple fact of thinking only about its health, has certainly not overcome suffering, illness and death. Quite the contrary. People fall ill, suffer and die of an illness and of a death which is increasingly without meaning and without hope.

We have gradually convinced ourselves that, once we have lost our health, there is no further hope, everything is lost. This leads to the growing repression of illness and death which we see in this present age, as well as a certain incapacity to give a satisfactory meaning to our lives. Every possible effort must be made by the individual and by the state to achieve that final goal which is, as the World Health Organization declares, “to enable every citizen to realize his birthright to health and longevity”. The individual desire, which in itself is understandable, of leading a healthy life for as long as possible, ends up legitimizing any public health initiative whatsoever involving our life. Woe betide anyone who is fat, or who smokes, or whose life style is “at risk”, or who produces children which are not perfectly healthy, or who leads a life “unworthy of being lived”. At the moment sanctions are imposed for only some these examples of behavior, but no one can exclude the possibility that one day they will apply to all. On the other hand, the use of human embryos for “medical” use, the most reckless techniques for assisted procreation, microchips in the brain to liven us up, various kinds of prosthesis, whether traditional or nanotechnological, to make us stronger and faster, have all become quite acceptable; even abortion is acceptable if it helps to improve the physical and mental wellbeing of citizens.

There we have it. But in this respect what is health becoming?

At the moment in which medicine intervenes upon “improvable conditions”, both medicine and health become indefinite concepts which no longer have anything to do with medicine and health as they had been understood up until today. Health involved a sort of “natural normality”, an equilibrium, which had to be re-established (this is the task of medicine) once it went out of balance, for whatever reason. Medicine today, on the other hand, has been taken over by technoscientific and financial considerations; it has become increasingly dependent upon sophisticated diagnostic equipment and upon related financial investments; it is concentrated above all around data banking and information systems, around pharmacological design and the development of medical technologies, to the point where medical control is now slipping increasingly out the hands of doctors, as a class, in the strict sense. But above all, I repeat, there has been a change in the objective which medicine seems to be pursuing today. Today, when we talk about “health” we mean something completely different to what was meant in the past. As Nikolas Rose has written: “All that medicine was able to hope for was to arrest the abnormality, to re-establish the natural vital norm and the normativity of the body that sustained it. But these norms no longer seem so inescapable, these normativities appear open to alteration. Once one has witnessed the effects of psychiatric drugs in reconfiguring the thresholds, norms, volatilities of the affects, of cognition, of the will, it is difficult to imagine a self that is not open to modification in this way.” (Rose 2007, 17).

A large part of medicine today therefore seems to be directed toward transforming and shifting human limits more than toward treatment. And Rose, in line with this, substitutes the work “care” with “life enhancement technology”. Medicine loses its particular characteristics, becoming absorbed into life politics, whose purpose is the optimization of human performance: so-called enhancement medicine. “Contemporary technologies of life,” once again in the words of Rose, “are no longer constrained, if they ever were, by the poles of health and illness. These poles remain, but in addition, many interventions seek to act in the present in order to secure the best possible future for those who are their subjects. Hence, of course, these technologies embody disputed visions of what, in life, may indeed be an optimal state.” (Rose 2007, 6).

We have therefore gone far beyond the concerns about “scientific medicine” which Karl Jaspers expressed in the 1950s. It is no longer simply a question of doctors being gradually reduced to simple “functions” (general practitioner, specialist, hospital doctor, specialist technician, laboratory doctor, radiologist) and patients being reduced to simple “clients” in an “establishment” which looks after them in an increasingly impersonal way, according to standardized procedures (the famous protocols), applied mechanistically to the illness rather than to the patient, (Jaspers 1999). The aim now is to produce a sort of new man.

In the words of Marc Jongen, thanks to biotechnology man is none other than an “experiment in himself”, an experiment which can finally crown the dream of creating a being which is superior to man (a recurring temptation from Nietzsche to Skinner and Peter Sloterdjik). We are therefore faced with a model which might include as “normal” the innumerable and disturbing suggestions in favor of making the right to life subject to the passing of specific genetic tests (made by Francis Crick and James Watson, who discovered the double helix of the DNA), or in relation to child euthanasia or the production of so-called “chimeras”, or any type of strengthening of physical or brain capacity: extolling the virtues of a sort of universal viagra.

It therefore happens that the gain in terms of efficiency, which is certainly achieved from our health system, is paid for in terms of “humanity”, as a result of the functioning methods of the system itself. A time such as ours, which is increasingly technicalized and functionalized, takes away with one hand what it manages to give with the other; it certainly offers great opportunities for tackling and curing illnesses which until now had been fatal without even being recognized, but at the same time it has brought about an exponential growth in our health needs, and our expectations, transforming illness and suffering into a sort of inacceptable scandal. We all, to a greater of lesser extent, live under the illusion that everything is technically possible. Even when scientific and technological development gives rise to a certain concern, in reality we nevertheless tend to think that our problems will be solved by science and technology. This increases the assumption that worldly phenomena depend above all upon us, upon our power; it exasperates our desire for happiness, offering a misleading picture, which is destined in itself to produce frustration. As for health, in this respect, it is no longer a gift – the most precious gift which God, nature or destiny are able to give to mankind – but becomes a “right” to be demanded at all cost. Anyone who is ill must necessarily be cured. Otherwise, the doctors are to blame. It is rather like what happens when there is an earthquake: the first thing we do is not to feel indignation about a loss of life which we feel perhaps to be unjust, but we hunt out those who have failed to respect anti-seismic standards in building the houses.

Indeed, what we are witnessing is a sort technological “craze” in the world. It is no surprise that the so-called advanced societies of the Western world are now seeing a great revival in magical rites and practices. Magic, as Max Scheler had well intuited, is not classified among the forms of metaphysical and religious knowledge, but instead among the forms of technological knowledge. We go to the magician or to the sorcerer above all because we find it impossible to accept, for example, that there is no cure for a certain illness; it is impossible not to know in advance whether this or that business deal will be successful, whether or not we will pass that exam, whether or not we will succeed in winning over the heart of that pretty girl, and so forth. Whatever does not depend upon us (in other words, the majority of decisive events in our life) is looked upon with increasing diffidence, almost ignored. Thus, through a sort of delirium of power, we are losing our sense of reality, our sense of our true good, and even our sense of normality. Through a series of “devices”, “stratagems”, “artifices” we have come to believe that everything depends upon us. And yet the things which really count – birth, death, health, illness, just to name a few – do not fall within this power of ours. Health, as Hans-Georg Gadamer showed, is not a “product” of the doctor, but “something natural in itself” (Gadamer 1974); it is so natural that we are only aware of having it when something goes wrong, when our “normality” is upset by the occurrence of something “exceptional” – the illness which requires us to go to the doctor in order to return to our “natural equilibrium”. But it is precisely this equilibrium which is made inconceivable by the logic of enhancement, the claim to improve human nature, which induces everyone, whether healthy or sick, to seek the services of the doctor, to go “beyond” – the go one stage further, whether in sickness or in health. Here, indeed, a certain form of biopolitics seems to be dancing its tripudium.

“It seems to me that one of the fundamental phenomena of the 19th Century was what might be called the assumption of responsibility for life on the part of authority. It is, so to speak, an assumption of authority over man as a living being, a sort of statalization of biological life, or at least of a trend which might be described as moving towards the statalization of biological life” (Foucault 1998, 206). This is what Foucault said in a lecture given in March 1976, noting with remarkable prescience the disturbing situation in present-day biopolitics. This, indeed, is the sense of the word “human” in “human life”, reduced not by chance to “bare life”, before being totally subjected to the requirements of an authority which defines its parameters (the beginning and the end, the value and the dignity) in purely functional terms, therefore without any reference to anything, such as humanity, which, far from being considered in functional terms, ought instead to represent the aspect which is not “amenable” to any kind of functionalization (Belardinelli 2008). In this sense, in the words of Francesco D’Agostino, biopolitics indeed becomes “that model which regards humanitas not as a condition, but as the product of a collective procedure” (D’Agostino 2008, 316) which, I would add, profoundly conditions the ethos of our society.

This is a challenge of gigantic proportions, which, in my view, could be summarized in this simple question: Does man still have a purpose, a task to carry out (a telos, as the Greeks would say)? Is there still a human normality? If we consider the matter carefully, it is properly this idea of normality which constitutes the principle target of the pervading biopolitical model inspired by enhancement. On the one hand, in fact, it might be said that things happen by themselves, according to a logic which goes beyond single individuals and communities. Eventually it is the interests of the economical, technical and scientific system which increasingly govern society. On the other hand, everything seems to be heading toward a more radical individualism, in the conviction that everyone should be entitled to realize their own desires for happiness however, wherever and whenever they wish to do so. These are two logical approaches, only apparently contradictory, which in reality support each other. Indeed, I would say that the “statalization of biological science”, as Foucault calls it, mainly takes the form of its radical individualization. This is rather like what happens in early 20th Century science fiction stories (such as Haldane’s The Machine Man of Ardathia or Huxley’s Brave New World), claiming the “right” to give birth to children however and whenever we wish, or of the right to choose how and when to die. Each seem to be no more than one step along the road toward, on the one hand, a sort of artificial ectogenesis outside the human body and, on the other, a sort of exit strategy, as we might call it, which is equally artificial, both under strict state control and thanks to which we can resolve, let us say, both the problem of discrimination against women and the ageing population or demographic reversal or social order. The same is said about health and the enhancement of human capacity. Nanotechnology, neuroscience and increasingly sophisticated physical and neuronal prostheses are indeed opening up the way toward a new man who could also be nothing at all like man.

These are the principal challenges which have to be faced by public ethics today. They are challenges which bring into play not only economic wealth – the productive, political or administrative system – but also the entire cultural heritage of a society, its indicators of health and well-being, its ways of promoting personal autonomy and responsibility and, finally, its capacity to regard itself still as being a society worthy of man. But these, I repeat, are also tasks which someone may unfortunately think of resolving in a functionalistic manner, considering simply what costs less in economic terms, or according to the norms (these also being functionalistic) of biopolitics. To give an example, in the face of the economic costs of certain illness, someone might consider subjecting human embryos or foetuses to genetic tests which guarantee their “quality” before bringing them into the world; a systematic campaign in favor of euthanasia could be a good strategy for alleviating the costs of a life which, becoming gradually longer, produces an increasing number of old people who are not self-sufficient; the technology of reproduction could become the most efficient way of regulating births and dealing with the population problem; brain microchips could become the solution for many problems involving public order; and so forth. Biopolitics has, in any event, already been active in these areas for some time. But precisely for this reason it is all the more important to achieve a prospective in which society is considered, portrayed and experienced as a series of relationships which recognize the value of the human person.

In the face of the enormous scientific and technical potential which we have available, a policy which places biological science in the hands of the state and disguises its inhuman and illiberal aspects, granting as a “right” what is simply a “desire”, can only be an ideological accompaniment toward the “posthuman” being which is so talked about. A great thinker like Juergen Habermas, among others, was aware of this. I have never been a great admirer of his thought and have many doubts about some of his recent views; nevertheless I think that Habermas certainly hits the mark when he speaks out against the risk of a “liberal eugenics” (Habermas 2002) which could destroy the very assumptions upon which, at least until now, in our liberal democracies, we have based the very idea of there being a common public ethos. What we are taking away from our awareness as free and equal beings is precisely the spontaneity of our birth and death and the “normality” or our life. But in this way the “human” aspect, the good of man, rather than being the unassailable reference point and criterion for our individual actions and policies in general, becomes a sort of end-product. As Hannah Arendt had shown long before Habermas, birth, the natural casualness of our coming into the world, is the image and the condition of our liberty; it is equivalent to the eruption into the world of a new unforeseeable event, a sort of re-beginning, which is then replicated in every genuinely free action; everything being carried out anew each time; the world being deprived of its routine, being prevented from becoming Spinozan “substance”. This, in very brief outline, is the nexus which Hannah Arendt establishes between birth and liberty. In other words, inhibiting natural spontaneity, the unpredictability of our birth, making it subject to our own power – something which biopolitics is happy to do – is equivalent to inhibiting our liberty (Belardinelli 2007).

Worrying also is the symbolic universe around which biopolitics expresses itself, is made attractive and, for this very reason, is most dangerous. It is a symbolic universe which seems to be well described by the ideology of what Lucien Sfez (1999) calls Full Health, “Perfect Health”, raised to the status of a normative ideal, the highest of all; the criterion of the dignity of our life; a “right” which biopower is obviously happy to grant. If we consider the matter carefully, there is a sort of common link between the definition of health as “complete physical, mental and social wellbeing” which we are given by the “World Health Organization” and the “indefinite medicalization” of society which Foucault described. The field of medicine becomes more or less indefinite; all of us, as a matter of principle, become “patients”, assuming that the distinction of health/illness still has any meaning. It is a fact that the area in which doctors intervene is no longer limited to illness but, in the name of enhancement, tends to colonize the whole of social life.

Enhancement medicine makes human improvement possible on at least four levels: cognitive, emotive, physical and in the extension of life. The technologies used for cognitive improvement are drugs such as Ritalin and Adderal; for improving state of mind, use is made of anti-depressants or, as would seem possible, Deep Brain Stimulation. This was created to alleviate the symptoms of Parkinson’s disease and consists of surgically implanted electrodes which operate in the same way as a brain pace-maker. For improving the body, there are numerous and various technologies. Aesthetic surgery is perhaps as old as mankind. But today there are medical possibilities such as exoskeletons, namely external structures for the human body which enhance power and resistance; highly sophisticated prostheses (such as those for Oscar Pistorius) which could enable us to run faster than our legs could do; not to forget also the so-called Brain Computer Interfaces: extremely sophisticated devices which strengthen human abilities with the help of computers; these include equipment which enable paraplegics to use computers, but also the possibility of computers being commanded by thought, thanks to a sensor implanted into the motor cortex (Brain Gate). With regard to the extension of human life, current research is concentrated on nanotechnology and in particular on “molecular machines”. Finally, so far as the most far-reaching experiments on the improvement of the human body, there is, as is known, genetic technology.

At the moment in which these improvements become possible, can we legitimately assume that they will not in fact become imposed upon us? Would they not produce highly dangerous discriminations? Who will be able to work without subjecting themselves to these “improvements”?

In this respect, I regard the provocation put forward by Francesco D’Agostino in the last Catholic “Social Week” held at Pisa to be most important. His proposal was to operate a “privatization of the bios”, i.e. to refuse the “public recognition of any biological category, starting with those involving life and death” (D’Agostino 2008). As I suggested above, the individualism which claims personal desires as “rights” is only the other face of the “statalization of biological life”. Therefore “in order to remove bios from the notion of authority it is necessary first of all not to allow it to be identified with the words public”. Human bios has an “intrinsic, pre-political value”, it cannot be reduced to biological standardization, nor to generalizations which would result from its “statalization”. It eventually leads to the re-appropriation of the meaning of our life and of our liberty. We cannot allow our public health system to decide it for us. It is better to have a medicine which is limited to concerning itself with our “bare life” than a medicine which perhaps fixes the standards of efficiency or, worse still, of dignity. And if this also has to mean renouncing discussion about a “right to health” I confess that this is something which does not worry me unduly. Indeed, I regard it as a form of precaution against not only the casual manner in which the rights to abortion, euthanasia and assisted reproduction are put forward, but also against the risk, unfortunately already real, that any kind of government is acceptable, provided that it guarantees health – health as defined, of course, according to the parameters of the “World Health Organization”. We have a right to be cared for when we are ill; we do not have a right to health. Each of these is “natural”; they form part of human normality. The wish to remove illness and death has no sense. The idea of being able to eliminate them would constitute the suppression of the human being himself, who, as I suggested at the beginning, in these very situations of extremity (suffering and death) has his own special methods of expression. In short, it is precisely when faced with a human being who is suffering or on the point of death that we see the most powerful emergence of the sense of our “humanity”. It is these lives beset with pain and suffering which desperately ask to be accepted and, indeed, to be loved in their weakness and in their alterity as human beings. It is in these lives that the light and the shadow of our common destiny are perhaps best reflected.

Being happy, living well, despite suffering and death: this is the true (and in certain ways also dramatic) realism which continues to remain behind the great Western Greek and Judaic-Christian tradition. This is the “salus” of which we perhaps have special need today, which we must look after and cultivate at least as much as bodily health, in the conviction that, when necessary, it might represent the most precious resource, even for our bodily health. Anyone who has looked after a sick person at least once well knows how a “healthy” spirit can provide serenity, strength, courage in dealing with the illness and how all of this has real, beneficial repercussions, even at a physical level. A form of “prevention” therefore.

In this respect we can indeed agree with Gadamer in saying “we all have to care for ourselves”, to learn therefore to more carefully “auscultate” ourselves and the world around us, our health and its true significance. The attention which we dedicate to ourselves, once again in the words of Gadamer “is something which in the long run will prove decisive if we are going to cope with the changed living conditions of our technologized world and if we are to learn and preserve what is ‘appropriate’, appropriate for oneself and appropriate for each one of us, namely that internal condition of equilibrium” (Gadamer 1996, 100-1).

We must not allow authority, whatever authority that might be, to establish what constitutes the “good” in our life. Nor, moreover, must we allow authority to establish the criteria for our “humanity”. This is the task, and also the challenge, which today’s biopolitics imposes upon us.

Bibliography

• S. Belardinelli, Bioetica tra natura e cultura, Cantagalli, Siena 2007.
• S. Belardinelli, La prospettiva della biopolitica, in M. Simone (edited by), Il bene comune oggi. Un impegno che viene da lontano, Proceedings of the 45th social week of Italian Catholics, Edizioni Dehoniane, Bologna 2008, pp. 345-357.
• F. D’Agostino, La prospettiva della biopolitica, in M. Simone (edited by), Il bene comune oggi. Un impegno che viene da lontano, Proceedings of the 45th social week of Italian Catholics, Edizioni Dehoniane, Bologna 2008, pp. 315-331.
• M. Foucault, Society Must be Defended, Penguin 2003.
• H-G. Gadamer, The Enigma of Health, Stanford University Press, 1996.
• J. Habermas, The Future of Human Nature Polity Press 2003.
• K. Jaspers, Der Arzt im technischen Zeitalter, Piper, Muenchen 1999.
• N. Rose, The Politics of Life Itself, Princeton University Press 2007
• L. Sfez, La santé parfaite. Critique d’une nouvelle utopie. Paris Seuil 1995.