The following is an excerpt from my thesis (Master of Bioethics), which was completed in 2004. I’ll be reproducing it here in a series of posts.
6. Summary and Conclusions
6.1 – Summary
I have been discussing the tensions that exist between utilitarianism and the Danielsian conception of justice in healthcare when attempting to identify the most appropriate principles to apply to decisions about resource allocation. That is, the tension between the teleological desire to maximise welfare and the deontological ideal of fairness. These competing points of view result inn significantly different conclusions when considering the moral permissibility of nanotech performance enhancement. The main points of note are referenced below.
6.1.1 – Therapeutic Enhancement
The utilitarian is less concerned with the morality of actions; they do not hold that the positive/negative distinction is of any moral significance. The only method by which decisions should be made in relation to the allocation of healthcare resources is by calculating the Quality Adjusted Life Year (QALY) benefit of any action, and subsequently seeking to maximise the total welfare that is produced. Alternatively, Daniels is of the opinion that the positive/negative distinction is morally relevant, and appeals to our intuitions about fairness by contending that we should act to improve the lot of the worst-off among us as a matter of priority, prior to giving consideration to interventions that are designed to benefit the welfare of those who are better-off. In this regard, the notion of normal species functioning is central, as it is thought to provide a baseline against which we can priorities who should get what treatment.
6.1.2 – Augmentation
Likewise with augmentation, the utilitarian is only concerned with the maximisation of the positive contribution to welfare. There is no distinction to be made between decisions to help the worst-off over enhancing the best-off. This is such that we may potentially find ourselves under a moral obligation to prefer a course of action that provides one person with superhuman abilities, over returning normal species functioning to another. Nor do they believe that any restriction should be placed upon how either public or private healthcare dollars are to be spent, over and above the requirement that we maximise QALYs. Daniels, on the other hand, suggests that priority be give to improving the worst-off in society over providing superhuman abilities to the better-off. In addition, Daniels would be opposed to the provision of private healthcare dollars towards augmentation, if doing so impacted upon the fair equality of opportunity experienced by individuals, as determined by their natural talents and abilities.
6.1.3 – Designed Evolution
designed evolution represents a further point of departure between our two competing viewpoints. Not only is the utilitarian supportive of programs of designed evolution, but this approval would extend to justify paternalistic polices intended to ensure participation and compliance. This would be permissible even against the wishes of the individuals involved, provided that doing so maximised QALYs. The deontic position avoids this conclusion by instead requiring a form of democratic mandate. The prospect of such programs does, however, raise interesting questions about the hybrid notion of normal species functioning that Daniels employs. Designed evolution could drastically alter social norms for functioning extremely rapidly, casting doubt on Daniels’ “uncontroversial baseline”.

6.2 – Conclusions
I have been attempting to determine how best to apply the two dominant competing principles of resource allocation in healthcare when considering nanotech performance enhancement. Both of these principle, then utilitarian QALY maximisation approach, and there Danielsian focus on justice, make assumptions about the scarcity of resources. The strength of the approach taken by Daniels is that it gives a voice to our intuitions about fairness. Yet, what is it that drives these intuitions? It would seem that the underlying feeling behind appeals to fairness consists in the idea that given a situation involving scarce resources, any decisions we make with regards to the distribution of those resources should not serve to promote social inequality. However, on the most optimistic predictions of futurists, nanotechnology may bring about a state of affairs in which the standard assumptions that are made in relation to the scarcity of resources will not hold true. How does this change our intuitions concerning which principle(s) to apply?
The utilitarian would no doubt be delighted by such a scenario, given the possibilities that it brought for increasing overall welfare via the satisfaction of individual preferences. On the other hand, Daniels is of the opinion that it is wrong to increase inequities in society. Yet, as we have seen, this assumes that the resources that were distributed to the well-off could, in fact, have been otherwise distributed to the worst-off. But what are we to make of actions that increase inequity even after we have assisted the worst-off as much as we can? That is to say that it may be possible for us to provide therapeutic enhancement to every person who required it so that they could return to normal levels of human biological functioning. But if it were the case that there were sufficient resources to also provide for augmentation to those already well-off (e.g. the wealthy), then social inequality between the worst-off and the well-off would still increase. Our question here becomes one of: is the inequity (i.e. the gap itself) immoral? This is certainly not the argument that is made by Daniels with respect to healthcare, and nor is it a position that is included in the theory of justice as fairness proposed by Rawls. There does not appear to be a remaining intuition with respect to inequity in and of itself. If this is the case, it would seem that we are left with utilitarianism as the most appropriate principle for guiding our decision making process with respect to the allocation of healthcare resources; i.e. that those resources be directed in the manner that will produce the greatest increase in overall welfare.
The possible benefits to be derived from nanotech performance enhancement are great, especially with respect to the potential for improving human welfare. IN fact, so great is the potential upside with respect to individuals, that allowing access to superhuman enhancement (i.e. augmentation) in a climate in which resources are finite, at the expense of the worst-off in society, is likely to produce social inequalities of a magnitude not yet witnessed. This represents an offense to our intuitions regarding fairness. As such, if we are confronted by circumstances in which the traditional assumptions about scarcity of resources are well founded, then I am of the opinion that the Danielsian approach is the one that should be employed. That is to say that our decision making process should involve the setting of priorities for healthcare expenditure, on the basis of perceived needs. Priority would be given to restoring normal functioning (i.e. therapeutic enhancement) over raising it to heretofore superhuman levels (i.e. augmentation).

In the absence of scarce resources, the framework developed by Daniels tells us nothing about how we should distribute our healthcare resources. Furthermore, in the event that it is possible to make nanotech augmentation available to everybody, there would presumably be those who simply elected not to alter themselves to incorporate such superhuman capabilities. These people might refrain from using the technology for any number of reasons, including:
- On religious grounds,
- Out of a preference to be “natural”.
This would have the potential to divide the human race in a manner not experienced since the evolutionary split between Neanderthals and Homo sapiens, and raises many compelling questions for future consideration. These questions include:
- What might be the social ramifications of such a split?
- What would happen to those left behind in the transition from human to trans-human?
- Is such a scenario desirable?
- Should society act to encourage/develop such technologies for the purpose of brining about this state of affairs, or instead seek to inhibit such an outcome?
In contemplating these issues, the utilitarian will only be concerned about the maximisation of welfare; i.e. if, on balance, more people are happier then it’s worth pursuing. At the same time, the conception of justice proposed by Daniels and Rawls appear inadequate if assumptions about the scarcity of resources are not true, rendering them unable to support our intuitions about inequality.
With regards to how best to allocate our healthcare resources when considering the proposed of nanotech performance enhancement, it does appear that if traditional assumptions about resource scarcity are invalid, then we should favour a utilitarian model of decision making. In this event, it needs to be stated that the utilitarian’s victory is not final. The way remains open for the development of a fresh deontological moral argument to the effect that any inequity created is immoral, in and of itself. This would need to be demonstrated to be the case, even after we have helped the worst-off in society as much as we can.
References
- Broderick, Damien, The Spike: Accelerating into the Unimaginable Future, Reed Books, Melbourne, 1997.
- Canton, James, “Designing the Future: NBIC Technologies and Human Performance Enhancement”, Institute for Global Futures, http://www.futureguru.com/articles, 2003 (Downloaded August 2004).
- Crandall, B.C. (ed.), Nanotechnology: Molecular Speculations on Global Abundance, MIT Press, Cambridge, 1996.
- Daniels, Norman, Just Health Care, Cambridge University Press, New York, 1985.
- Daniels, Norman, “Equal Opportunity and Health Care”, in Bonnie Steinbock, John D. Arras, and Alex J. London (eds.), Ethical Issues in Modern Medicine, pp. 164-167, McGraw-Hill, New York, 2003.
- Glover, Jonathan, What Sort of People Should There Be?, Penguin Books, New York, 1984.
- Grey, William, “The Ethics of Human Genetic Engineering”, Australian Biologist, Vol. 9, No. 1, pp. 50-56, 1996.
- Hardorn, David, “The Oregon Priority-Setting Exercise: Quality of Life and Public Policy”, Hastings Centre Report, Vol. 21, No. 3, pp. 11-16, 1991.
- McKie, John, Richardson, Jeff, Singer, Peter & Kuhse, Helga, The Allocation of Healthcare Resources: An Ethical Evaluation of the ‘QALY’ Approach, Dartmouth: Ashgate, Aldershot, 1998.
- Nanotechnology Victoria, Industry Focus: Textiles and Manufacturing, http://www.nanovic.com.au, October 2004.
- Pethokoukis, James, “The Red-Green Divide Over Human Enhancement”, Tech Central Station, www2.techcentralstation.com, 2004 (Downloaded August 2004).
- Rawls, John, A Theory of Justice, Harvard University Press, Cambridge, 1971.
- Swiss Re, “Nanotechnology: Small Matter, Many Unknowns”, Risk Perception Series, http://www.swissre.com, 2004 (Downloaded August 2004).