Is there a difference between medicine and enhancement? An interview with Anders Sandberg.
Anders Sandberg did his Ph.D. in computational neuroscience at Stockholm University on neural network modeling of human memory. He is currently a James Martin Research Fellow at the Future of Humanity Institute at Oxford University. Between 1996 and 2000 he was Chairman of the Swedish Transhumanist Association.
Kate Womersley – Your websites show the wide range of your interests and areas of expertise, but how do you introduce yourself and what you do?
Anders Sandberg – Quite often I jokingly introduce myself as an academic Jack-of-all-trades. I’m not really an expert on anything in particular, which means that I’m rather suitable for a philosophy department. Another way of presenting what I do is that I’m a lapsed computational neuroscientist who got really interested in the question, “how can you become smarter?” That’s how I ended up at the Future of Humanity Institute.
KW – At REMEDIA, we want to understand how enhancement relates to the past, present and future of medicine. Can you outline the different forms of cognitive enhancement and how they connect to clinical science?
AS – The big issue I got involved in first, and the reason I ended up going away from computational models of memory into thinking about ethics and social impact, is pharmaceutical enhancement. I was fascinated when I realized that there are actually drugs that can improve memory. I started reading up on the literature and I noticed that there are a lot of brain functions that can be affected by drugs in ways that improve cognition. It’s interesting because people are actually already enhancing themselves this way, although we don’t have any proper drug development per se in order to improve normal brains, we just get it as a side-effect of standard pharmaceuticals. People started to realize that the healthy test subjects also benefitted from the drugs, not just the sick people.
To give a quick overview of other methods, there are various types of brain stimulation. The classic form is trans-cranial magnetic stimulation where you wiggle a magnetic field to induce currents in the cerebral cortex. If you do this at the right frequency you make the cerebral cortex more excitable, and at a lower frequency, less excitable. This can be used to change and enhance mental processes. More recently people have been rediscovering that direct current stimulation on the scalp also seems to have similar effects, and it is of course much easier and cheaper to do. You don’t need a nice figure of eight coil and all the electronics. You just need a pair of electrodes and a battery. This leads to situations where amateurs are literally trying to make thinking caps, which is seriously scary for researchers and ethicists.
KW – Clearly you have a very optimistic outlook about enhancement and its potential. But you’ve also criticized the public assumption that enhancement is different from medicine, that it’s ‘evil’ or some kind of unsettling ‘anti-medicine’. Can you talk more about that?
AS – On one level speaking as someone in a philosophy department, you could say that the public is just confused. There is no clear distinction between enhancement and medicine. After all we have sports medicine where the main point is not just to patch up athletes but help them perform really well. You have all kinds of preventive medicine. You have cosmetic medicine, and so on. The harder you try to figure out a border between enhancement and medicine, the harder it becomes to argue that there is a sharp one. This is the majority professional ethics view.
But acknowledging this fuzzy border is not how most people think. To most of society there are clear categories: enhancement over here, and medicine over there. And typically I think the intuition is that we want to pay for the medicine that helps our neighbors; we want to be nice to them. But we are more skeptical about enhancing our neighbors. That is something they should pay for themselves. Maybe it’s some kind of unconscious thinking, “oh, they’re going to compete against me if I enhance them”. Or maybe it’s some kind of prioritarian idea: “well, we should help the worst off, that’s why we really ought to be paying taxes towards a communal healthcare system in which enhancement is an optional extra.”
In practice people have an even more confused view of this. It’s confusing from a philosophical perspective where you want things in neat categories. Friends of mine, L.S. Bergström and N.Lynöe, did a survey of GPs and normal people in Sweden about their views of enhancement. In general, a fair fraction of them felt that enhancement is a good thing, but still many thought that it’s a bad thing. Even so, if enhancement was framed as taking a natural remedy in order to achieve the same end, 25% more people felt it would be a good thing. From an ethics perspective it’s pointless to consider whether something is a pill or a leaf, but from the practical perspective – what people accept or think is good – it really matters.
This shows that we have weird perspectives about the means we use, but also our intentions matter. In the same survey the researchers told subjects that in some cases the enhancement was intended to help the person taking the substance, and then in others it would indirectly help third parties by making them more capable, like a surgeon getting better at operating. Of course when it was framed in an altruistic manner, people were much happier about the ethics of enhancement.
KW – Do you think people’s attitudes towards enhancement are conditioned by the healthcare system they are familiar with, so for instance different countries within Europe compared to the US?
AS – Yes, I think it’s both a healthcare system question and also the concept of what health is: what you’re expected to do and what is regarded as part of healthcare. The white lab coats and pill world, versus natural remedies. I once saw in the student cafeteria at Stockholm University that there was bread for sale with extra ginseng. This was bread intended to enhance cognition. So where is that on the spectrum between bread and pills? Well, somewhere in-between. The funny part is that many students who are happily buying this bread with the intention of helping them study would have been very skeptical if I had said, “what if you take this little white pill”. Pills have side effects, but natural remedies never have side-effects.
KW – This is interesting when you look at how companies market their products to appeal to our human desires to improve ourselves and extend our capacities, but not excessively so that it unsettles customers.
AS – Yes, and what is unsettling depends very much on the culture. I think there is a romanticism going on at the moment in western civilization. ‘Natural’ is regarded as good, and artificial is evil. That’s the basic part, but things get more complicated because certain artificial products are seen as pure and clean, while certain natural things are seen as dirty. This gets into all kinds of wonderful, complicated anthropologies of medicine. And of course marketing plays a big role.
My favorite paper on enhancement was actually published in a marketing journal. It’s about the fundamentalness to self of different personal traits. So they asked students how fundamental things like kindness, language ability, being awake, were to their sense of core identity. And then they asked students about whether they would like to take a pill to enhance these traits. The results of course showed a very nice anti-correlation. For things that are really central to your sense of self, you’re going to be very skeptical about improving them. Only 9% wanted to have a kindness pill. But it’s fascinating because in a sense that could be seen as the most important pill for humans. I have some colleagues who would argue that you almost have a moral duty to take a kindness pill. Meanwhile, people were quite ok with a pill to improve memory because that is a cold property, that’s not really you. It’s just something you use.
This also shows that people might be easily swayed because they don’t have such pills in their everyday life. You can frame enhancements in different ways and then people will be more or less likely to take them. If little white pills like Ritalin and Modafinil were dispensed as liquid in coffee cups, people would think about them in a very different way. The affordances of things like coffee and tea have interesting powers. It is practically impossible to overdose on caffeine in coffee; you simply can’t drink enough because your stomach can’t hold it. At the same time you can get various aesthetic pleasures out of the taste of coffee. At least us coffee drinkers do, but I have a colleague who when we’re working on a joint project, grudgingly comes with me, holds his nose, has a coffee, and drinks it as medicine. But most of us think of coffee as beautiful. It has culture. We talk about good baristas, we might be showing off a bit about our different blends and so on. But there’s nothing we can say about the Adderall pill, except, “I think that the Novartis version is slightly better than the GlaxoSmithKline one.”
KW – You have spoken about the problem of “naïve enhancement”. How would you define this and where do you see it in today’s world?
AS – A lot of people have a magical view about how things work. A pill: you might take it not to affect a particular function in your body, but as a kind of symbolic act to fix your problems. Essentially it’s magic. And it’s going on all around us of course, not just in enhancement. An awful lot of patients go to the doctor in order to be healed, although what needs to be healed may not be a physiological function but a social or spiritual matter which is beyond what any doctor can do. Many people think that the Adderall pill will help them get smarter and do better at school. Of course that’s not going to work. A pill will help if you’re doing something which requires focused attention. But it might be a very bad thing to do when you’re driving, as you’ll then just be focusing straight ahead. Something that improves your memory is great, but it’s not going to help you do an ‘all-nighter’. All-nighters are stupid because you don’t get any memory consolidation. They are only useful for writing up a lot of text before a deadline but are not going to help you remember anything for an exam. People don’t want to learn a lot of cognitive neuroscience to improve their performance though. The more you know the better you will get at using the tools and cognitive resources. You want to use the tools as quickly as possible, but not invest a lot of time in taking a neuroscience course.
KW – Do you think that the limitations of public outlook and legal regulation are fueling naïve enhancement? How might we encourage conversations so that people are kept safe but are also allowed to explore new possibilities?
AS – I think an important part is gradually de-stigmatizing enhancement. That was part of the reason that I chose to out myself as having tried Modafinil in The Times a few years back. I realized that a British tabloid was going to figure it out anyway and I wanted to make sure it was old news and uninteresting. It also led to a key ethics question: what about the ethics of the ethicists writing about the ethics of the thing they’re actually testing. Interesting self-referential questions here about bias and how personal experience might influence your judgment.
In my native Sweden, drugs are really taboo. The US and Sweden are partners in the global War on Drugs. Sweden is the good cop talking about rehabilitation. The US is the bad cop who says, “let’s bomb those poppy fields”. Britain seems more liberal. We certainly have less regulation about the misuse of drugs, but still a lot of moralism. It’s clear that many students are using enhancers and maybe not in the best way. Certainly we could have better discussions taking place if the tabloids didn’t get involved.
KW – So do scientists, philosophers and medics in this field have to be exemplary individuals in their ethics and outlook?
AS – If you had to be exemplary to do ethics, ethics would be empty. There is rather good evidence that ethicists are actually slightly more dodgy than most philosophers. More ethics books are stolen from university libraries than any other, for example. If you go back in the history of philosophy, it seems that Spinoza is probably the only nice ethicist you can find. We can’t rely on people being exemplary. In ethics and philosophy, you go by the arguments. You don’t really care who made them or what kind of person they are. You just ask whether theirs is a good logical argument for doing something or not. You might notice all the same whether or not they followed it up themselves. This goes for a lot of science too. The problem is that bias can creep in via many different ways. In pharmaceutical journals the papers involve many methods and assumptions which are unwritten, assumptions going on in the lab which are difficult to report on. But I think it’s useful to have a human aspect to our discourse about these new technologies, and not just theoretical ideas about what’s right and proper, but also how enhancing yourself actually feels.
KW – Can there really be safeguards and checks on drug usage? Who would be responsible for them?
AS – I certainly think there can be safeguards. Some safeguards are very simple. Even if you had a total laissez-faire market where everyone was allowed to buy drugs, you can imagine consumer organizations doing tests which ask which enhancers do what. You can also imagine something like Yelp reporting back on user experience. In a sense you already have this. There is a website called Erowid where people report online about psychoactive drugs. In most self-reports it is totally impossible to tell what’s going on because certain effects, experiences, not to mention the weird noxious mixtures people are taking, remain unclear. But this could be done in a proper manner. And we can, as a society, encourage it through formal discussions and by gathering data. One idea that might make sense would be to allow doctors to prescribe enhancers, but patients would have to pay for them and enroll in some kind of testing. Your doctor might check that your blood pressure is compatible with a particular enhancer and verify that you don’t have any contra-indications. While the patient tries the substance, they could give some data back to allow society to figure out whether these drugs actually work. The big question I want to know the answer to is whether Adderall and Modafinil help students. Anecdotally people say they are useful, but we don’t have good data. It would be great to have an rigorous, valid study. It could turn out that a lot of the drugs are not used in the right manner so they don’t really make much of a difference.
KW – Your research is often brought up in the in the context of transhumanism, and you see yourself as a transhumanist. Can you explain what this word means?
AS – I see transhumanism as the idea that you can question the human condition and ask which parts of it we can improve. The philosophical side of my brain then immediately interjects, “how do you define improve?” Typically this improvement is focused on technological means. Humanism has for a very long time tried to improve the human condition by using means such as education, rational societal institutions such as democracy, fostering tolerance and so on. Transhumanism says, “that’s great, let’s add on some other things”. Aging for example, that’s not good and it’s not something we necessarily have to have. We know there are organisms that don’t age like we do, and we know that biochemical processes can be altered. So it would probably be a good thing to slow the rate of aging and even perhaps to reverse it. Also my own area asks, “wouldn’t it be a good idea if we were smarter?” Again, you can discuss why we should be smarter, whether it’s an instrumental goal or whether intelligence itself is something intrinsically valuable. People have different views. I’m more on the instrumental side. Enhancement extends us to the trans-human condition. Critics say, “yeah, but in that pursuit you’re going to lose the good parts about being human.” And then the quarrel begins. It’s unlikely that we would want to do away with the good parts of the human condition.
KW – If enhancement progresses at the current rate, as seems inevitable, do you think this will lead to greater diversity or greater uniformity amongst people?
AS – I think a mixture. In a sense we have greater uniformity in health today, as most of us are very healthy. If you look at pictures of people from just a few generations ago, many more of them had obvious disabilities and illnesses with disfigurements. We have fixed this through modern medicine. Our current lack of diversity is a great thing. We don’t want the diversity of leprosy. But on the other hand we want diversity of ideas and of types of life. We want a society which is rich and tolerant enough to have people who live very different lifestyles which enrich the totality of society. Even if it doesn’t make much sense to anyone else, it’s a good thing that there is that outsider artist doing those very strange art works.
I think we want more diversity in some directions and less in others. The direction we want to remove diversity is where it is hurting us. There are times when we are morally obliged to do this, such as cruelty. It is part of the human condition, part of how our limbic system works somehow, to take enjoyment in the pain and suffering of those we dislike. But that is not a good thing. I think we would be a much better species without that diversity. So the real challenge is what kind of things we can do to ensure we don’t lose diversity. Francis Fukuyama’s critique of transhumanism argues on one level that we are going to lose diversity as we become Prozac-chewing, standardized and very bland people. But then on the next page he assumes that there is going to be a huge divergence which will undermine democracy. He’s both having his cake and eating it. It’s a really lousy argument, but it does show that both of these elements are present in criticisms of the transhumanist project.
I think it is important to ask whether you can set up institutions to defend diversity. I have been arguing in favor of morphological freedom, that we have a right to our own bodies. This also means we have a right to change our bodies, but that right is also a negative right. I am allowed to say, “my autonomy forbids you from upgrading me, although you think it would be good for me.” This is getting into standard medical ethics questions about the limits of patient autonomy, but as long as we are talking about reasonably sane people who are reasonably well-informed about the procedure involved, I think this should be uncontroversial. These ethical arguments need to be carried over into laws and institutions as well as norms in society. So when my boss comes into the office and says that I should be taking an enhancer to be more productive, I should be able to stand up against him.
KW – In media scare stories, the word ‘eugenics’ comes up in the same breath as enhancement and transhumanism. Can you explain the differences and similarities between them?
AS – Eugenics started out when people realized that humans have a genetic system like animals, and like animals you can breed them for certain purposes. Many projects emerged which aimed to produce better humans. These projects fell into disrepute because they were based on bad science and a center of power that imposed a one-size-fits-all view. They were coercive. In contrast, you can imagine a liberal eugenics which gives parents a choice about the traits desired for their embryo. There is not going to be one mistake that affects the whole population, and it’s not coercive. There are some interesting fiddly questions still about whether it could be considered coercive to the embryos and the persons they are going to be. But leaving aside these philosophical fine points, there is still the concern that maybe the selection criteria are going to be stupid. Perhaps we’ll get a generation of blonde-haired, blue-eyed rather tall people. But I think that’s self-correcting because it means that people who are not blue-eyed and blonde are going to look exotic, which will give them an advantage.
Eugenics is problematic because it starts out by creating a particular kind of person. The sort of enhancement I’m particularly interested in works on an existing person and tries to improve them. An existing organism is really complicated. There are a lot of systems in the brain which cannot be re-wired, no matter how much electric stimulation is done and no matter how many drugs are taken, even if I try and implant some electrodes. They have been fixed by our genetic system and our developmental processes. Eugenics and other genetic techniques affect the whole organism which is their great strength, but that is also their biggest drawback: they’re really slow. It will take you twenty years before that enhanced child is adult enough to be able to make use of their enhancements. Twenty years in science is a long time. By then we may have a pill that does the same thing. I think that genetic engineering of children is something that might exist and have certain uses, but it is not going to be totally transformative. It is pervasive and profound but requires time and data, and that’s tough.
KW – How strong do you think the influence of genetics is on an individual as opposed to their environment?
AS – Quite often you have complicated interactions between the two. Many smart people have grown up to be smart because they seek out exciting and stimulating environments where they get a lot of experience which trains their brains. To some extent it was not the intelligence genes that made them smart, but those that made them adventurous which helped. The types of environment might really matter too. Studies of intelligence show it’s heritable, but more heritable for upper-middle class Americans than lower-middle class Americans. For upper-middle class children the environment is as good as it can get. The main difference might be between a fine-tuned and a really fine-tuned brain. Whereas if you’re in the ghetto, you have a very dangerous and messy environment which affects you.
And that is only along one dimension. There are many other dimensions which affect how well our lives go, aside from intelligence. Just think about motivation. I know that if I had grown up in another place other than 70s Sweden, I would probably have stronger motivation and have been a much more successful academic! I’m totally lazy and laid-back about a lot of things and allow opportunities to go by. Although perhaps I’m a happier person this way…
Understanding these interactions requires a wider perspective than looking at more than just genes. I was blogging yesterday about a model I made which shows the simple fact that even if smart people have fewer kids, it doesn’t necessarily lead to the degeneration of intelligence as a lot of people predict. Understanding the science takes more than knowing genetics. We need to look at each person’s individual environment, which is going to be a real challenge for future data mining.
KW – You have said that the big problem with doping and enhancement in sport is not just the effect in sport itself, but how this changes norms and rules outside of athletics. What do you think will happen to the spirit of sport in the future?
AS – The problem with the anti-doping crusade we see now is that it’s making it harder for non-athletes to enhance themselves. In many countries there are strong laws against anabolic steroids, which are unconnected to the actual harm they might be doing. Since they are banned in sports, and sport has a lot of political and social capital, it has led to wholesale bans. At the same time, a lot of people are getting therapeutic treatment which would not be regarded as enhancement and doping for athletes. We have a paradoxical situation where many people watching sport have access to treatment which would be much more complicated if athletes were taking it. Things get more complicated still by the fact that many athletes have a staff of sports doctors who know just how far they can bend the rules. This gets to the conundrum about the spirit of sport.
The spirit of sport is a slippery thing which many people have different views about. The reason most people like watching sports is that they are exciting, unpredictable and you can cheer for people doing something amazing and feel that you are, in a vicarious sense, linked to them because you’re of the same nationality and so on. If that is broken, people may say they don’t want to watch anymore. But the fact that the Tour de France cyclists are nearly all taking something or other doesn’t stop it attracting viewers. It’s exciting nevertheless. It’s as if people accept that it’s part of the spirit of sport that sportsmen are secretly doing these things. But the anti-doping agency officials would argue for a more puristic view. They say that these forms of enhancement do not belong. But then again a lot of current training methods would have been viewed by past generations of athletes as totally super-enhancing. Critics of enhancement worry that if you enhance too much, sport won’t be about humans anymore. And who wants to watch post-humans perform? To which I reply of course, “people love to watch monster truck racing”. It might be very different to normal racing, but if we agree, “yeah, that’s the sport”, then it should be alright.
I think health arguments are much stronger. Many athletes are willing to sacrifice anything to win, including their health. So where we perhaps should put down our foot is by saying that athletes are allowed to compete fiercely, but we shouldn’t allow them to destroy themselves. It doesn’t matter if there are any drugs involved or whether it’s super-motivation that makes them compromise their life by competing.
KW – Where do you think this urge to enhance might end? Is there an imagined aim – biological, intellectual or aesthetic perfection – even if it does not in fact exist?
AS – A lot of people naively assume that there is some kind of perfection. But the further you go in any direction typically you realize that you have a lot of choices. Take for example, cognitive enhancement. Its not that you take a pill and become smarter across the board. If I take a stimulant, I’m going to have more energy and motivation and a little more alertness. Whereas, if I take Adderall or Ritalin, I will be more focused. Other kinds of enhancer will affect memory, but not motivation. So I have a choice here about what I actually want to achieve. And not all enhancers work well together.
There are some general-purpose areas where I think we all just want more. We all want more health, for example. We want to live as long as we wish, and we probably want to ensure that our bodies do not deteriorate just because we’re sitting in offices all day. Here ideally we would get muscular, athletic bodies without much exercise. But you can only take this so far. If we imagine a drug which would make our muscles grow even when sitting at a desk, it’s hard to think how it could tell my body which muscles to develop. If I go to the gym, I can train particular groups of muscles in accordance with a training program and the everyday activities I do. So for a comparable effect, I would have to somehow program the drug for a particular outcome. Similarly, with life extension, we may need to make certain choices about which aspects of our bodies lengthen temporally. Perhaps extending the immune system’s longevity will not prove to be compatible with keeping our skin looking nice. To which some people might say, “I’d rather be beautiful and just live to 120”, whereas others might decide, “I don’t mind the wrinkles, I just want to see 500.”
KW – Programmed particularity will certainly cost money. Do you predict the emergence of a medically enhanced elite and a gaping difference between the most and least enhanced humans?
AS – Socioeconomic class difference has something to do with this gap, but I don’t think it’s only to do with wealth. It’s also about social capital. Typically we see health differentials across all societies, even those where everyone has access to pretty good healthcare. And the reason is probably due to stress. Knowing that you’re low on the totem pole is bad for you. Yes, you can go to hospital where clinicians can perform treatments on you, but your everyday life is affected by knowing that there are people better off than you.
On the other hand, the actual cost of enhancement doesn’t have to be high. Any gadget or pill typically becomes exponentially cheaper over time. Services are more expensive. I like to point out that we might well have a moral obligation to automate as much of medicine as possible, to make more gadgets which can be produced cheaply. This may not be good news for those born to be doctors or nurses, but it is good for humanity to spread medical tools to more people who really need them. Social capital is much more difficult to redistribute than money or access to services. A lot of people who lack social capital don’t even realize that they may have access to medical services, which is worrying.
Most of the discussion about enhancement is framed around upper middle class values after all. It’s about your career. It’s about doing well at university (of course you’re going to go to university). It’s about a professional job which uses your brain rather than your brawn. But many people might have different values and nobody is asking them what they want to enhance. Given the spam I’m getting in my mailbox, we know that sexual enhancement is what a lot of people are actually concerned about. The enhancement debate is fixed to a clinical, workaholic perspective, but there are probably many more forms of enhancement which we haven’t been able to touch at a similar level because we haven’t managed to handle the ‘normal’ part yet.
KW – How do you suggest we might broaden discussions beyond this middle class perspective, and across the boundaries of academic disciplines?
AS – Universities are interesting because academics are smart people who overestimate how important intelligence is in order to succeed in life. So we’re already getting a bias towards cognitive enhancement. While I would argue that intellect is useful, we need motivation and emotional balance too. But these are studied very separately from cognitive enhancement. Academically, we do tend to split things up so that the bio-ethicists don’t talk to the pharmacologists, and neither of them has even thought about going over to the law faculty to ask them, “what is actually legally possible here?” Getting over these disciplinary boundaries would be a first step.
I think another important part is that as scientists, we have a duty to interact with the public. But just going out to talk to people in the pub is not very effective as that reaches only one person at a time. I think science blogging is one useful way. It does not reach everyone, but it allows you to engage a bit further. As new infrastructures for social discourse are created on the internet we must use them well.
KW – Finally, could you recommend some articles or books you’ve read recently which offer surprising and thought-provoking perspectives on enhancement?
My old friend Ramez Naam has recently returned to the genre of science fiction, but before that he wrote a book about enhancement from a therapeutic perspective which is really good. Another interesting take is Rebuilt by Michael Chorost which has the subtitle, ‘How becoming part computer made me more human’. It’s about his experience of getting a cochlea implant. He presents some of the issues about current man-machine interfaces from the perspective of a smart patient. It doesn’t turn into a story of a technophobe who gets converted to how cool technology is, or a technophile who realizes how awful technology is. It’s rather nuanced. There are some interesting discussions about the interactions between technology and specific communities, such as the deaf community, which has been struggling with the question of what to do about their children. Should they grow up with a sense their parents lack? If yes, it means that deafness is going to slip out of our culture.
And we all might have the same dilemma with our children and grandchildren. Should we give them an implant which could provide them with new communication abilities, although this might mean that they will invent a culture we cannot even fathom?