A Confucian Appraisal of Justice in Genetic Therapy and Genetic Enhancement

1
A Confucian Appraisal of Justice in Genetic
Therapy and Genetic Enhancement

• Graduate Institute of Philosophy
• National Central University
• Chungli, Taiwan ROC Chou Wan-ling

2
Introduction

• Since the completion of the Human Genome Project,
  biomedical development has entered the era for
  genetic interference and it sheds new hopes for
  the treatment of genetic diseases. It will bring
  along rapid increases both in our understanding
  and our capability in the control of genetic
  constitutions of our life and a new era of
  genetics has dawned before us.

3

• Once the technology of genetic therapy and
  genetic enhancement matured, we shall face the
  ethical problem of how to make use of them.
  Should we employ these techniques for the
  treatment of genetic diseases as well as enhance
  our power through genetic enhancement? Do we
  need to provide such services to all in terms of
  justice?

4

• This paper will examine the issues with Norman
  Daniels first and goes on with a Confucian
  evaluation of the problem and degree of
  employment of genetic interference. Whether
  there are reasons for the acceptance of genetic
  therapy and/or genetic enhancement. What
  difference the Confucian view makes in comparison
  with Daniels.

5
Daniels right to health Care

• Daniels theory of just health care derives from
  John Rawls. He thinks being healthy is the
  qualification condition for everybody to enjoin a
  fair equality of opportunity. An individual need
  to have health for him/her to compete fairly with
  others, and can strive after one's own
  expectation of ones life . So, the right for
  fair equality of opportunity is to have
  everybody's health taken care of first.

6

• Health means a state without disease, and
  everybody have a right for cure if possible.
  Therefore the definition of health will influence
  the range and restrictions that healthcare should
  cover.

7

• Daniels concept of health is adopted from
  Christopher Boorse.
• Boorse ' definition contains a teleological view
  and regards various kinds of bodily organs have a
  definite purpose and they serve the various
  functions of the species.

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• To put it simply. Boorse regards health as the
  ability that a member of a species normally
  possesses. It is a kind of standard frame of
  reference for a normal individual of the species.
• Disease is an interference or destruction of the
  standard normal function of the species, that is,
  disease deviates from species normal function
  operation.

9

• Daniels divides medical institutions into four
  layers and accord to them a sort of priority in
  the sharing of medical resources. It is based on
  the principles of justice especially the socalled
  fair equality of opportunity while in effect, it
  is in accordance with the concept of species
  normal functioning.
• Daniels emphasized that there is but one concept
  of justice, not four different principles of
  justice. It is in their relation to the
  maintaining or restoring an individual to the
  normal species functioning that it is thus
  stratified.

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• First Layer Prevention
• Daniels seems to assume that our health state is
  usually at our species normal functioning.
  Hence, the first thing is to maintain our health,
  that is, prevent our health being deteriorated.
  Such suitable precautionary measures, including
  public health service, environmental cleanliness,
  preventive personal medical service, occupational
  health and safety, nutrition education and so on,
  which promotes healthy life.

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• Second LayerRestore.
• Because not all deviation from health could be
  prevented, the system must offer service for the
  recovering of health, to help patients returning
  into the state of normal species function.

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• Third Layer Compensation.
• Some kind of diseases or disabled could not be
  restore to the normal species functioning level,
  we need to extend medical service for the
  compensation of such deviation to make the
  patient as close to normal as possible.
• It includes diseases such as chronic patient, the
  disabled, the frail elderly.

13

• Fourth Layer Terminal Care
• Some serious diseases and terminal patients, they
  could not be brought near to normal functioning
  at all and thus require related health and social
  care. This kind of patients brings issues with
  justice, they involve the virtue of benevolence.

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• These four layers contain more or less a person's
  health care needs in life. It is ideal that the
  nation could look after all four layers.
  However, the extent that these needs be satisfied
  depends on social and public resources, including
  its economic and political states.

15
Daniels on Genetic Therapy and Genetic Enhancement

• According to Daniels concept of right to health
  care, any medical treatment that could restore a
  patients health is morally acceptable. In other
  words, since genetic therapy could help to
  restore patients to their normal species
  functioning, they are acceptable and under the
  first three layers of institutional medical
  services. People could request such kind of
  service or therapy, under the condition that
  society could afford the resources,.

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• In this sense, those diseases that could not be
  brought back to normal species functioning
  through genetic therapy would not be eligible for
  such treatment. They are beyond the call for
  justice and would fall into the fourth layer of
  health care services.
• Genetic enhancement is beyond the normal species
  functioning thus not what a just society needs to
  provide.

17
Confucianism on Genetic therapy and Genetic
Enhancement

• The development of genetic technology inevitably
  brought forward genetic therapy and genetic
  enhancement as a new kind of medical treatments.
  They are often dubbed playing God by religious
  groups. Would Confucianism regard them as moral
  or not?

18

• According to Confucian conception, Tao has the
  virtue of procreation and nourishing all living
  things. However, the procreation process may not
  fully realize and some lives may have defects and
  crippled. To cure such defects and diseases is
  for Confucianism a moral responsibility and a way
  that human being participates Tao.1
• 1 Professor Shui Chuen Lee calls this the
  participation of the nourishing process of Heaven
  and Earth, see his, Confucian Bioethics, chatter
  4, pp.53-69

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• Diseases is a kind of defects and medical
  treatment is regarded basically a human act in
  the direction of assisting the procreation and
  nourishing process of Tao, hence, whatever kind
  of curing of diseases and saving of life is
  morally acceptable for Confucianism

20

• For Confucianism, a human being has two sorts of
  natural endowment, one is his or her talent, the
  other is morality as a human being, that is, his
  or her acting as a moral agent. According to
  Confucian principle to let every living thing
  manifest to the utmost of their natural
  endowment1, a just society should provide every
  member in his or her different life stages an
  opportunity for the utmost manifestation of his
  or her talents and morality.
• 1 Concerning the details of this principle,
  please refer to Shui Chuen Lees Confucian
  Bioethics, pp.53-69, and his paper on Justice
  and Equality in Health Care A Confucian
  Critique, presented in the Eighth World
  Bioethics Congress, Beijing, August 2006.

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• The first kind of endowment means that a just
  society should let its members develop their
  talents without any unnecessary interference
  while the second kind of endowment is what makes
  a human being reach the full manifestation of the
  highest value of a human being, that is,
  participating the procreating process of Tao or
  Heaven and Earth and becomes a sage in the full
  sense.
• Hence, the principle of utmost extension of ones
  nature requires our health care provide more
  service than Daniels right to health care.

22

• In general, Confucians will accept Daniels broad
  distinction of the different kinds of medical
  service but will not limit the right to health
  care to the first three layer and must extend it
  to the fourth layer as well.

23

• Genetic therapy is basically included in the
  first three layer and will be accepted by
  Confucianism as appropriate as such institutions
  will lessen pains and sufferings of human beings.

24

• Some may doubt that Confucianism lays great
  emphasis on naturalness, would not approve the
  kind of artificial interference of genetic
  therapy. However, this misses the Confucian
  conception of nature and the nature.
• Confucian would not take the Taoist attitude of
  objection to any human interference of nature,
  but instead a sense of nature that is in line
  with Tao and humanity. The act from humanity for
  the assistance of the procreation of Heaven and
  Earth is a participation of Tao and raises human
  being into the status of forming a trinity with
  Tao. Confucianism regards it as a highest virtue
  achievable for a moral agent.

25

• In fact, for Confucianism, general medical
  practice, saving endangered species,
  environmental protection, are perfectly acts
  participating the nourishing process of Tao, or
  what should be morally done.
• If genetic therapy could cure patients, Confucian
  would not object it because it is a kind of
  interference.

26
Three different forms of Genetic Therapy

• 1.Potential Genetic Diseases
• 2.Manifested Genetic Diseases
• 3.Therapy that brings also Genetic enhancement

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• The first kind refers to the kind of genetic
  diseases that are regarded as having a definite
  probability of infliction to the subject.
• If genetic screening discover the potential risk
  of a genetic disease which could be cured through
  direct genetic interference, Confucianism will
  endorse such genetic therapy as long as the kind
  of genetic treatment is matured to a reasonable
  degree.

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• For Confucianism, diseases are painful and such
  suffering, no matter it is physical or
  psychological, it will affect the personal
  development of the person. According to the
  principle of utmost extension of each ones
  natural endowment, any element that obstruct
  personal development should be removed, a just
  society need to provide resources for such
  relief.

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• The second kind are those genetic diseases that
  have already infected the subjects and thus would
  be off the mark of normal species functioning.
• It is not prevention but a need for restoration
  and thus in accord with the second layer.
  Genetic therapy could stop such genetic diseases
  to have further worsening effects on the body as
  a whole and it may provide cure through
  regeneration of lost parts so that the patient
  may return to normal functioning and relieve from
  sufferings. It is definitely approved by
  Confucianism as morally compelling for the
  society to offer to such patients.

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• The third kind is more controversial for it
  involves genetic enhancement. For instance, it
  may happen that in curing retardation in
  intelligence, the patient may become a genius of
  some sort. It would impinge on the problem with
  enhancement.
• Is it morally acceptable that when curing a
  defective gene, the treatment brings along
  enhancement?

31

• For Confucianism, genetic therapy is for the
  curing of genetic diseases which affects the
  subjects development, the side effect of
  enhancement will not be a counter reason for such
  treatment.

32

• As with genetic therapy, if genetic enhancement
  could help people to have a fuller development of
  his or her natural endowment which leads to
  better social harmony, Confucianism will accept
  it with qualifications.
• For Daniels, the difference between genetic
  therapy and genetic enhancement is that the
  former fits into the definition of disease while
  the latter is not. If it is a genetic disease,
  it is genetic therapy and has the right to
  proceed, if not, it is enhancement and the
  society has no responsibility for its provision.

33

• Though Confucianism accepts the distinction of
  genetic therapy and genetic enhancement as
  Daniels did, social justice is not defined
  according to the criteria of a disease. It
  encompasses more. It includes those that could
  be labeled as defects. If certain enhancement
  could enhance such defects, Confucianism would
  accept it as a remedial for justice.

34
The Content of Genetic Enhancement

• There are two kinds of personal traits that may
  be enhanced
• One that is judged as socially good, excellent
  genes, such as high intelligence, logical power,
  understanding, as well as kind, considerate,
  benevolent, generous, etc, which are socially
  approved personal traits.
• Another one is the socalled negative personal
  traits, such as indifferent, cruel, selfish, and
  certain special features that could distort the
  normal body functioning such as being very
  elastic.

35

• For the first kind of personal traits, if they
  could promote a better and more harmonious
  society, so that human society as a whole
  improves, Confucianism would be likely to allow
  such kind of enhancements, though Confucian may
  think the key lies with education and social
  relationship development rather than genetic
  determination.
• Hence, if ones request for enhancement is solely
  for personal gains would not be approved by
  Confucianism, for consideration purely for
  personal gain is a somewhat selfish act and would
  lead to others being in a less competitive
  situation. It would cause more conflict and
  bigger gap between social classes.

36

• Besides, if only those who could afford the cost
  for enhancement could be accessible to it, it
  would result in more social injustice and wealthy
  people will have better resources for the
  accumulation of further wealth, while the poor
  will be harder to move upward.

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• In other words, Confucianism would approve
  enhancement under the condition that all members
  have equal access to such resource and that the
  quality of life in the society as a whole is
  improved.

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Concluding Remarks

• There is not much objection to genetic therapy as
  it likes traditional medical practice, only that
  it makes use of more direct interference with the
  source of illness. There seems no moral reason
  to stop it. The difference lies only with the
  range and restrictions of such manipulations
  which is guided by the concept of justice.

39

• Daniels will limit the application of justice
  only to the case of deviations from species
  normal functioning. Thus, genetic therapy is
  parallel to traditional therapy and will be
  limited to the prevention, curing and restoration
  for normal functioning. Genetic diseases which
  could not be released by genetic therapy are not
  subjected to the requirement of justice and would
  be out of the reach of justice and right to
  treatment. They are more likely fall into the
  realm of social welfare which depends on the
  resources that a society could afford.

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• Confucianism would regard the extension of the
  right for treatment to the fourth layer is a
  requirement for justice. Social benevolence is
  included in the realm of social justice. Genetic
  therapy should be extended to the fourth layer,
  though the service provided depends upon the
  resources of the conditions of the society.

41

• Daniels would regard all kinds of genetic
  enhancement as out of the bound of social
  justice. Confucianism approves enhancement with
  qualifications.

42
Genetic era will leads to our better control of
our body but only cautious and restrictive
employment of such technology would bring
happiness and prosperity for human being as a
whole.
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Thanks for your attention