Cognitive Neuroenhancement: health, cultural and legal issues Sara Fernandes, Centro de Filosofia da Universidade de Lisboa Abstract New developments in neuroscience, especially since the Decade of the Brain, have made neuroenhancement an important domain of philosophical reflection. Neuroenhancement is usually understood as any intervention (natural, social or technological) on the brain that aims to improve its capabilities beyond clinical therapy and good health (better intelectual performance and abler minds) and even as a form of generating happier persons. In this paper, it will be sustained that the goal of neuroenhancement, like cosmetic surgery, fits in and is encouraged by the current conception and practise of medicine. After, the paper will identify and describe some cultural roots of neuroenhancement (greek myths, literature and films), which characterize human nature and western civilization. The last issue of the paper will discuss if it is fair to use biotechnological power to achieve human desires of unlimited cognitive enhancement. Based on John Rawls’s Theory of Justice, firstly, the paper will argue that fairness requires equal rights for all persons. In this regard it sustains that one of the necessary conditions of a fair neuroenhancement is safety for all citizens, or at least a prudential weighing of its potential benefits and risks. This is the first step to provide citizens fair conditions for a well informed decision and a fair way to exercise other basic rights, as freedom of thought and freedom of will (personal autonomy). Secondly, in accordance to Rawls and its second principle of justice, enhancement is unfair unless there is equal opportunity for all to obtain it. Enhancement can lead to exacerbating inequalities, if it is not guaranteed equality in opportunity to all citizens in the same circumstances. Thirdly, the paper will sustain that the respect for the difference principle is the third necessary condition for fairness in neuroenhancement. If the cognitive achievements are safe and maximize the wealfare of all, it should be regarded as fair. Yet if cognitive enhancement promotes more inequalities between people it should be considered unfair. Keywords: neuroenhancement, cosmetic, human nature, western culture, John Rawls philosophy@lisbon, 9, 151-169. Lisboa: CFUL. Sara Fernandes 1. Neuroenhancement: Towards a Brain Cosmetic? Neuroethics, a term created by Zach W. Hall and William Safire, was born as an academic field at the beginning of the 21st century in the USA. Like bioethics, it is a field of multidisciplinary research, which seeks to reflect on the ethical, social, legal and anthropological issues raised by the remarkable neuroscientific and neurotechnological progress of the last decades.1 Adina Roskies divides Neuroethics in two main branches of inquiry: the neuroscience of ethics and the ethics of neuroscience. While the neuroscience of ethics is specially interested in understanding the neurobiological basis of moral reasoning and behaviour, the ethics of neuroscience is a broader domain, also divided in two subdomains, ‘the ethics of practice’ and the ‘ethical implications of neuroscience’. The ethics of practice is concerned with the clarification of ethical principles that should conduct clinical practice and brain research, while the ethical implications of neuroscience evaluates the philosophical, ethical and social impact of neuroscientific advances and our growing understanding of brain functioning.2 The philosophical problem raised by brain enhancement was born in this last neuroethics field - ethical implications of neuroscience –, despite its direct and obvious relation with the neuroethical branch ‘neuroscience of ethics’, since any neuroenhancement will always have a biological correlate and also an impact on personal behaviour. What is neuroenhancement? It is the ability to use certain resources (natural, social or technological), not for a clear or objective therapeutic purpose, not to treat a disease in human brain or to rehabilitate dysfunctional brains, but to improve human capacities, such as cognitive or affective functions, in healthy individuals. Let us imagine that in the future we have the possibility of becoming the person we have always idealized by simply taking one pill: less timid, more intelligent, more uninhibited, more assertive, in short, what corresponds to the imaginary of each one us. If it were possible to delete the psychological traits we do not like in us and increase what we enjoy in ourselves, would we do it? And should we do it? Moreover, these questions lead 1. HALL 2002: 1-2. 2. ROSKIES 2006: 18. Cognitive Neuroenhancement 153 to a more general one: is is ethical and fair to help people accomplish their unlimited desires? “Cosmetic psychopharrmacology”, an expression coined by Peter Kramer at Listening to Prozac, is currently used to describe the technological attempts to enhance the brain without direct and explicit clinical purposes.3 Certainly, brain interventions go much deeper than the skin4 and target our most important organ, the organ without which we can not live or if damaged, may unable us to live well. Why call it cosmetic? Is it an intentional way to devalue the enhancement project, to highlight its futility and deny its clinical purpose? Is it a superficial way to ignore its dangerous effects on personal identity and humanity? Or is an expression that better accounts the human future and the unavoidable uses of medicine? Cosmetic surgery is already legal in western countries, as a way to better shape the body, to accomplish personal desires (for instance, to prevent aging, improve beauty, assume a gender and sexual identity), far beyond the clinical traditional approach, confined to surgical restoration and bodily reconstruction from physical diseases or accidents. Physicians and people in general will always have different perspectives regarding plastic surgery and its place and role in the medical activity. The main reason to be suspicious about this connection is the belief in a traditional view of medicine, exclusively dedicated to the prevention, treatment and cure of illness and disease. This belief still remains the core of the medical profession and its ethics. However, if we look closely to the current WHO (World Health Organization) guidelines, with its positive and holistic definition of health, we understand the need to broaden our view of health and medical practice. Although it is controversial to define health, as «a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity»,5 since it establishes health as an ideal, a goal achievable only by few, it surely widens our conception of health. Now, the medical profession is not limited to prevent and treat illness and disease, and the healthcare system surely exists to help people achieve and persist in this excellent biological state. Accordingly, subjective judgements and feelings of patients are important 3. KRAMER 1993: xvi, 15. 4. SANDEL 2007: 2-4. 5. https://www.who.int/about/mission/en/ Consulted on 16-10-2018. 154 Sara Fernandes to clarify and help the physician define the state of wellbeing in each specific case. Moreover, the new ‘Hippocratic Pledge’ (2017),6 which really emphasizes patient’s rights, the respect for his autonomy and dignity, also stresses the importance of each person to assess his own quality of life and well-being, in short, his own health. Although controversial for neuroethicists, I believe that brain enhancement is neurocosmetic, and so it can also fit into the physician’s role. It makes this role to be also the promotion of patients well-being, going beyond just treating disease and healing. Like plastic surgery, that changes the body to improve it, to turn it better or more beautiful, the goal of brain enhancement is to improve psychological skills in healthy individuals. In short, when critics of neuroenhancement stress that their acceptance and legalization may have consequences in medical practice, because it may alter our understanding of concepts such as ‘health’, ‘disease’, I claim that their meanings have already been modified (broadened) scientifically and socially by institutions with scientific authority for many decades. And it is precisely because it has changed the meaning of ‘health’, illness and disease, since 1948, that it is important to reflect whether it is ethical and just the medical prescription of neuroenhancers.7 So the question is: if plastic surgery is legal, as I have tried to show, because it fits into the ethical principles and medical activity, even taking into account the level of risks associated with any clinical intervention, why can not brain enhancement be also legal? Is it wrong to consider brain enhancement a ‘lifestyle’ service, among other medical specialities, as ‘cosmetic surgery’ or ‘cosmetic dermatology’ in a near future? Surely, one crucial issue to take into account is the level of risk of any intervention, whether it has few side effects or it is really dangerous to health. But let’s suppose brain enhancement has a low level of risk, as cosmetic surgery in general does. Should we considerer it permissible in this case, namely, psychological moods, cognitive traits (like memory), in short, the personality itself? Or is there something more profoundly disturbing in manipulating one’s mind? Even if no harm is involved, isn’t there something worrying with brain 6. https://www.wma.net/policies-post/wma-declaration-of-geneva/ Consulted on 16- 10-2018. 7. For this discussion see: GLANNON 2007: 112-113; CHATTERJEE 2004: 968-974; CHATTERJEE 2006, 110-113; DEES 2004, 951-952. Cognitive Neuroenhancement 155 manipulation?8 If so, what makes it disturbing and eventually wrong? If not, how should one philosophically assess these ethical and antropological fears? 2. The cultural roots of neuroenhancement. Long before medicine opened the way to biotechnology and the possibility of neuroenhancement, we find in Western culture many examples which highlight the creative power of Man, the ambition for perfection, but also the danger of becoming a victim of excessive ambition, of wanting to take on the role of God and of being able to extinguish personal identity and human condition. The desire for enhancement, for self-improvement shapes human nature: better intelectual performance, abler minds, happier persons, more healthy, longer lives, the desire to be better than well in all domains. Yet, at the same time, the fear of playing with our unknown power, the ‘fear of playing God’ or to interpose in the nature course, the fear of the future and the unknown, also shapes us.9 This view of human nature, founded and expressed in these everlasting conflict feelings, crosses western culture, from Greek Mythology (the Myths of Prometheus and Pandora, Icarus and Daedalus, just to mention some examples), passing through the Gothicism (as Mary Shelley’s Frankenstein show) to contemporary literature, (for example, Aldous Huxley, Brave New World, and Philip K. Dick’s novel Do Androids dream of electric sheep?). Let us remember that Prometheus was condemned to suffer forever because he challenged the gods, who had just endowed Man with all the necessary talents and knowledge to survive as a species. Among them was fire, with which Man could control other beings and dominate nature.10 As a punishment by Zeus, Pandora descends to Earth and opens her box to disclose the pains and harms of human condition: greed, envy, hatred, pain, disease, hunger, poverty, war and death. After showing all the evils, there was still hope in the box, which Pandora let fly to show also to Mankind that it is possible, with human talents, to touch the wounds created by the evils and heal them. Pandora has freed the pain and suffering in the world, but also allowed 8. SANDEL 2007: 1-20. 9. SAFIRE 2002: 4-5. 10. BULFINCH 1985: 10-17. 156 Sara Fernandes hope to arise in Mankind.11 In the same way, the Myth of Icarus and Daedalus symbolizes the excess of courage, the arrogance of all men who do not recognize the limits of their power. Nevertheless, this fiction is also one of the first incitements to overcome the limits and constraints of the human condition.12 I do not consider it to be a simple teaching on the harmful consequences of the unlimited ambition of mankind. Daedalus, father of Icarus, succeeds in this challenge, since he escapes from the labyrinth and survives, symbolizing the good use of knowledge and technology, the accomplishment of a dream, although at the cost of an immeasurable loss, the death of his son, Icarus. However, as Walter Otto sustains, this eternal duplicity is the “delight and torment” of human nature.13 Many centuries later, in 1818, when Mary Shelley wtote Frankestein or The Modern Prometheus, it made us reflect again about the unlimited desire of Man to seek new knowledge, the human fascination with controlling Nature and technologically manipulate it, but also about the ethical and antropological danger of creating artifitial life.14 The ideal was to create an enhanced, perfect being, exclusively due to human knowledge and power. However, the original greek optimism and hope on human talents, well noticed in the myths, were lost with Shelley’s Franskenstein. The lesson is clear: it is impossible to absolutely predict and control Nature; more crucially, there will always exist some domains beyond human understanding which should not be pursued. For Shelley, artificial manipulation, including the brain, only for the sake of knowledge and individual improvement, is wrong, not only because of its unpredictable and possible terrible effects, but also because it shows the darker and shameful side of human nature (coldness, pure calculus, neglect and abandonment, shame, violence and crime). The creature, in many moments of the novel, seems to be more human than his maker, Victor, showing the need for love and care, the need to create afective and social bonds, and also personal and social pain when experiencing lonelliness and lack of relationships. 11. JORDAN 1993: 210. 12. BULFINCH 1985. 13. OTTO 1979 :24. 14. SHELLEY 2015; SAFIRE 2002: 4-5. Cognitive Neuroenhancement 157 Contemporary literature and films carry on Shelley’s perspective and emphasize much more the dark and cold side of Man, trapped in his technological creation,15 which will lead to the extinction of the human species and the transition to a post-human state of life. In The Brave New World, Aldous Huxley’s goal is to raise awareness of the ethical, social and political dangers of biotechnology: in the future, people will use drugs to calm themselves, improve their self-esteem, increase their attention and concentration, their cognitive abilities, and adapt to social standards. In the future, children will be raised to live up to the expectations of their parents, women will give birth to other species, hybrid beings and human life will be very long, but the last 50 years of their lives will be lived alone, without family and with poor health. For Huxley, this great change due to biotenology will be imposed by governments without the conscience and consent of citizens, in order to create an obedient society, the dictatorship of technology. Quoting Leon Kass, the great threat of biotecnology, its widespread use is that “Contrary to man degraded by disease or slavery, dehumanized beings in the manner of Brave New World are not miserable, they do not know that they have been deprived of their humanity, and what is worse, if they knew they would not care with that. They are, in fact, happy slaves, enjoying servile happiness.”16 Similarly, Do Androids Dream of Electric Sheep? (1968), a book by Philip K. Dick, which inspired films, like Blade Runner, offers a projection of the future, exploring science and technological progress, making us think about our ‘human’ nature, our existence in relation to other beings, and also to feel some fear about its impact on the world we live in. It is the drive to mastery and to change nature, to remake and create artifitial beings according to human purposes (‘replicants’ in Blade Runner), that should concern us. This novel shows us that a pure mechanistic perspective of life is false: replicants, beings manufactured by humans and to satisfy human desires, also start to look by themselves for a life with freedom and meaning. Also, it shows what we can do to other human beings in a technological future, as we already know from our past: a new apartheid, a world divided in two types of beings, where one group is considered a simple workforce 15. CORREIA 2018: 2-3. 16. KASS 1985: 35. 158 Sara Fernandes available to humans, with no rights.17 Therefore, although physically very similar, there is a difference between the two types of beings, defined by their mode of conception, one generated in the laboratory, the other born naturally. This difference establishes a qualitative difference and a hierarchy between them. The novel and Blade Runner films also show that what makes us unique and human is deeply based on this capacity to think creatively, to act and live autonomously, to make decisions. It isn’t human to live in a determined way, without conscience, as if we were predestined robots. In this regard, as the diversity of life shows us, there are “more human than human” replicants, there are enhanced and dangerous replicants, as there are human beings with all these good and bad traits. As Shelley’s Frankenstein, Philip’s Dick novel and Blade Runner films explore the idea, from the replicants side, of living in a world where they do not have rights, a recognized identity, but they feel they have it all and like many humans they value the gift of their lives, regardless of their artificial origin. These last examples from literature suggest that advances in science and technology can have a profoundly negative side, a massive dehumanization. Still, we have to ask if neuroetically this is possible. What can this dehumanization mean? As Gazzaniga lucidly suggests: «we are talking about a practice that exists only because of the very nature of being human: to discover, to think, to figure out new ways to do things. How, then, can using this very human skill, using the brain, the thing that makes us human, be acused of “dehumanizing”? 18 Surely, the dehumanization portrayed in the previously discussed works is related with lack of positive afective bonds, artificial alienation (Franskenstein, Brave New world, Do Androids Dream of Electric Sheep)? based on a excessive human will to power. There is still more dehumanization in Brave new world: people reject their freedom, their critical spirit and authenticity, in the name of permanent well-being, not caring about being enslaved. In fact, we can imagine a future where most people lack the most important traits that define humans. Surprisingly, some of these features could be only kept by a few tyrants, and this is really dehumanizing, although Gazzaniga defends a diferent argument, as stated before. Literary fiction and cinema, using symbolic speech, should make 17. LAPOINTE 2017: 24. 18. GAZZANIGA 2006: 53. Cognitive Neuroenhancement 159 us think, but the fascination with knowledge, curiosity of the unknown should not be stopped or redirected in its objectives, unless it is clearly recognized that its effects are not beneficial, will produce bad outcomes, or in a deeper level, if it is not good for Mankind. Facing science with fear and mistrust may limit scientific research and progress, rather than promoting it, especially when people frequently believe that scientists are interested in doing pure science without ethical concerns. The simple fear of change or more complex fears, as the creation of the recipe for immortality or the creation of artificial machines more perfect than human being and therefore dominating and enslaving humanity, are just a few some examples of this. As Gazanniga proposes, one of the main goals of the neuroethic debate is to try to ‘eliminate the slippery slope’ argument, do not fall into extremisms, and be guided by reason.19 It is certainly important to reflect on the social implications of this power and the possibility of neuroenhancement for personal identity and humanity in the short and long term. Yet, to be successful, we shoud have two levels of philosophical reflection and speech. First, it is important to distinguish between what seems to be scientifically possible and what seems to be definitely fiction; second, as we can never foresee with absolute certainty how far scientific knowledge can go, precisely because science is always making other things possible, we should also ask what would be the anthropological, ethical, and legal impact of neurorenhancement if it was possible, effectively real. We should not ignore western culture warnings and lessons, but we should not also be dominated by its symbolic discourse and emphasis on the emotions. The domain of philosophy is reason, and one of the features that distinguish philosophy from art is its ability to analyze human emotions rationally. In both philosophical levels, the answer to the challenge of neuroenhancement should be done with good sense, guided by ethical standards, and a reasonable speech should prevail. This is our aim in this paper. The desire for research, the fascination for discovery, is part of the human condition, and with science we are effectively discovering new things; but as soon as new discoveries are achieved, the scientific community also reflects on their importance and the negative and positive consequences they may have. Certainly there are risks as19. GAZZANIGA 2006: XVII. Sara Fernandes 160 sociated with genetic engineering, psychopharmacs, and we can not say that there will be no abuses, ethical and socially wrong uses of this knowledge, but history has taught us (for example, nuclear bomb, which was never used more, although persists the knowledge to build it) that we are able to re-evaluate scientific and technological findings, realize what is genuinely good for the human species and make an ethical and reasonable use of technological knowledge.20 With regard to neuroenhancement, it is expected that neuroenhancers will be developed in the laboratory for three fundamental reasons: firstly, precisely because they fall within the conception of humanity that we have started to outline; secondly, because they fit in the medical research line and its current definition of health; thirdly, natural resources have always been used for this purpose (like coffee and tea) and social such as education and meditation) over time. Thus, the antrological and medical path is traced so that artificial neuroenhancers are developped, and maybe will allow us to be faster and more effective in what we want, spending less time. Although Gazzaniga warns us that «they will be used and misused»,21 it is our responsibility to philosophically reflect on its social implications. 3. Is Neuroenhancement Fair? In addition to the anthropological and ethical implications discussed earlier, there are also important legal issues to reflect. Neuroenhancers raise the crucial problem of whether their use is socially fair. This problem brings up a set of questions, as should the Law regulate neurooenhancement? If so, for what purpose? To preserve some definition of human nature? Or human rights?22 Or should the State back away from any intervention and let instead citizens decide the course of their lives, also on behalf of certain fundamental rights, such as freedom? We will discuss this philosophical problem and its questions having as reference A Theory of Justice by John Rawls (1971). Rawls sustains that fairness requires, first of all, equal basic rights for all persons.23 The right for healthcare is one of these basic 20. GAZZANIGA 2006: 54. 21. GAZZANIGA 2006: 69. 22. GREELY 2006: 246. 23. RAWLS 1999: 13. Cognitive Neuroenhancement 161 rights and one of the primary duties of the State.24 The State has the duty to promote preventive healthcare, as well as treatment, cure and rehabilitation of its citizens. Thus, the question of safety is central to enhancers, and one of the necessary conditions for its fair use. There are five important reasons why the issue of health safety is a central one for neuroenhancers, and should be considered first and foremost: Firstly, pharmacological enhancers and brain electrical stimulators, which are currently eventually used, are, above all, clinical and therapeutic resources. Therefore, although regulated its safety and efficiency by the FDA in the United States, and other institutions of scientific authority in most of the developed countries, it is impossible to ensure that they are absolutely safe. There are always predictable side effects, more or less severe, described in the clinical information, and it is very difficult to identify rare risks in clinical trials. Secondly, enhancement is currently an off-label use of clinical drugs. Therefore, although it is of physician’s responsibility to prescribe it, the drug has not been tested consistently in healthy people. Therefore, it is crucial to evaluate the risks of neuroenhancement in people with no identified diseases. Neurotechnology was designed to promote health in human beings, not to cause disease. Thus, and thirdly, it is difficult to decide how regulatory institutions could define neuroenhancers safety. There are approved medications with high side effects for the treatment of severe diseases, such as certain forms of mortal cancer, but for enhancers, it is difficult to accept high or even moderate health risks.25 Fourth, there are enhancers marked as ‘dietary supplements’, like coffee, chocolate, or other common substances, as tobacoo and energetic drink, which are not subject to such strict trials, although subjet to minimum regulation, because they are not intended to treat diseases. Lastly, and in a deeper level, it is also crucial to reflect how can we regulate the safety of enhancers if our main concern is that neuroenhan24. http://www.who.int/mediacentre/news/statements/fundamental-human-right/en/; https://www.parlamento.pt/Legislacao/Paginas/ConstituicaoRepublicaPortuguesa. aspx Consulted on 18-9-2018. 25. As Henry Greely states, «[…] FDA would require much greater safety for drugs to treat relatively minor ailments. How much risk should we allow in a drug that does not treat a disease but improves normal function? If it were to weigh the risks against the health benefits of the treatment, it might require almost complete safety.» GREELY 2006: 258. 162 Sara Fernandes cement can radically change our identity, our conception of the person and, in a broader sense, human nature. For example, existential concerns start immediately when we think about the possibility that certain drugs, used to treat very serious situations of post-traumatic stress, can also be used in people considered healthy and selectively erase their bad memories. As Glannon argues, it is not clear how institutions would test these existential and long-term effects.26 Now suppose brain enhancement has a low level of risk, or is absolutely safe for healthy people. Thus, let’s suppose that the first necessary condition of Rawls Theory of Justice is satisfied, and people receive all the information they need to weigh prudently its potential benefits and risks. This is the first step to provide citizens fair conditions for a well informed decision and a fair way to exercise other basic rights, as freedom of thought and freedom of will, to be able to decide autonomously. A consequentialist weighing of its benefits and damages is enough to decide if it is ethical and fair? Or, are there other reasons, besides safety, which should be considered to evaluate its social fairness? According to Rawls and its second principle of justice, enhancement is unfair unless there is an equal opportunity for all to obtain it. For some neuroethicists, this is also a crucial issue do discuss. Neuroenhancement can lead to undeserved rewards and accentuate social differences, even leading to the creation of different castes. Specifically, in competition contexts, enhancement can often be regarded as cheating and a way of accentuate inequalities, if it is not guaranteed equality in opportunity to all citizens in the same circumstances.27 Like doping in sports, which is considered unfair, cognitive enhancement presents strong similarities, because physical and psychological enhancers can be both used to improve attention, productivity and competition (e.g. for students to learn faster and thus have a better school performance), and allow some people to achieve “undeserved” success.28 Cheating and increasing inequality are obviously related. For example, if someone cheats in competitive contexts, performs better, is more successful, and has more rewards, then cheating can lead 26. GLANNON 2006: 113. 27. CORREIA 2018: 4. 28. FARAH 2012:13. Cognitive Neuroenhancement 163 to unequal outcomes.29 This idea is based on a principle deeply rooted in western democracies: the belief that people’s opportunities should also be deserved, opportunities should be shared according to the talent and merit shown. So if someone uses psychopharmaceuticals or steroids to have better performance and success, and this behavior goes against norms objectively established, since intentionally breaks social contract rules, then it is a form of cheating.30 There is another important issue regarding the principle of equal opportunities: neuroenhancement could be a new source of unfairness, especially to those who would not have access to it. This would lead to new forms of social inequality. As Levy argues, these ‘exacerbated inequalities’ can diminish empathy and solidarity among people, since the favored and the disadvantaged will feel very different from one another. Disadvantaged people may feel strongly that inequalities are undeserved, therefore undesirable and unjust. But the advantaged may feel much less need to contribute to the collective good and start to face the disadvantaged with a conception of innate superiority.31 Thus, to retrieve justice, the alternatives neuroethicits identify would be to prohibit the neuroenhancer or make it equally available to all who desire it, either being free of cost, or being accessible to all (eg. providing subsidies to those who could not afford it).32 Yet it is unrealistic to think that enhancers will be safe in the short term, and even if safety will be guaranteed, it is unlikely that enhancers will become available to all autonomous people who want them in all countries. For most neuroethicists, the lack of equal opportunities is a strong fair reason to object to use neuroenhancers nowadays. However, it is easy to identify a set of worldwide neuro-empowering social interventions that are already allowed, and violate the second principle of justice, by being unequally distributed within societies and across countries. A good diet, a good health system are not well distributed in the world, both between developed and developing countries and within countries; we know how these socio-economic 29. LEVY 2007: 123. 30. LEVY 2007: 123-124. 31. LEVY 2007: 92-93. 32. MEHLMAN 2003; GREELY 2006: 259. Again, neuroenhancement would only be fair if it is respected Rawl’s second principle of Justice - equal opportunities -, and firstly basic rights, such as the right to health (not harming the well-being) and the right to freedom of decision (autonomy - it is up to each well-informed adult to choose whether to take neuroenhancers or not). 164 Sara Fernandes differences are crucial in personal development (intelligence, health) and lifelong performance. Educational environment is also a good example of social disparities: the possibility to send one’s children to the best schools, and to receive the best education, being daily exposed to a cultural environment where knowledge and thought are valued, are important advantages for those who are part of them. No one will apparently conclude this is cheating, because is allowed by social rules, but it is clear how social advantages contribute to create enhanced people since early age.”33 Yet, little has been done worldwide to reduce this unfainess in complex social environments, which means that they are only available to a privileged minority. So long as these inequalities remain, it should be concluded that we live in unfair societies. We should genuinely worry with this social gap. Even contemporary democratic societies are still characterized by durable unequal opportunities (for instance, in education, in health) and, therefore, fail short of collective justice. For most neuroethicians, existing inequalities are expected to be stronger if neurotecnhological enhancers start to be available in the market. It is to be expected that only the privileged will benefit from neuroenhancers and in an increasingly disproportionate way when compared to the disadvantaged.34 According to Rawls’s second principle of justice, neuroenhancement would only be fair if it respected the principle of equal opportunities. More specifically, if cognitive achievements are safe and maximize the wealfare of all, it should be regarded as fair. But if cognitive enhancement promotes more inequalities between people it should be considered unfair. Thus, the respect for the difference principle is the third necessary condition for fairness in neuroenhancement. As Rawls argues, social differences and socioeconomic advantages of certain groups are only considered fair if they combine the principle of equal opportunities with the principle of difference. This means that the position and expectations of the most favored are only legitimate if and only they also contribute to improving the socioeconomic status of the underprivileged in society.35 According to the principle of difference, there is only social gain when other members also 33. Neuroscientific and neurocultural enhancements «lead to greater intelligence and success, which leads to wealth which enables further enhancement.» LEVY 2007: 93. 34. LEVY 2007: 126-127. 35. RAWLS 1999: 65-66. Cognitive Neuroenhancement 165 improve their position. Thus, with regard to neuroenhancement, we might consider fair its use by the most favored, if with this measure, it results in the benefit of all members of society, specifically the disadvantaged. For example, if cognitive empowerment of the most favored contributes to develop scientific or technological work that helps everyone, including the most disadvantaged, improving their cognitive performance and social insertion, it should be considered fair.36 Furthermore, cognitive neuroenhancement of the most disadvantaged could also be considered fair for two reasons: firstly, the encouragement to improve the best traits of each person is the way people fulfill themselves in democratic societies and have a good life, with access to goods like self-esteem and social recognition; thus and secondly, neuroenhancement would reduce the relational and cognitive difficulties of the disavantaged, and would allow to get closer to the established social pattern and be in a better position to enjoy social opportunities. In these cases, the principle of difference never overrides the principle of equal opportunities, so I believe these cognitive neuroenhancement proposals would be considered fair and justifiable in Rawls’s philosophy. Regarding neuroenhancement, one way to generate fairness in societies, would be to make it accessible to all, including the most disadvantaged, as is already done with other resources, such as free books, and the internet.37 We know that changing social opportunities, by changing social structures, is predictably longer and more difficult than using psychopharmaceuticals. So this is another strong reason to promote it, if Rawl’s first principle of justice is guaranteed. By subscribing to Rawls’s perspective and, to that extent, against Nozick’s view, no one deserves the conditions in which is born, promising or harmful, and for this reason it is the State’s duty to promote equity of oportunities and to promote more positive measures to correct social inequalities. Contrary to Thomas Nagel negative view of Rawls perspective of social justice, according to which Rawls does not value personal merit,38 I would say that Rawls is in favor of merit and his primary interest in Theory of Justice is to lay down the fundamental principles that allow that everyone, without exception, can develop their potential 36. CORREIA 2018: 4. 37. CORREIA 2018: 1-4, 12-15. 38. NAGEL 1973: 222. 166 Sara Fernandes with protection and security, the necessary conditions to achieve the greatest merit possible in society and live a good life. Cognitive neuroenhancement could be one of these measures. It should be clear that the goal is not to create an equal society, where everyone has the same cognitive abilities, the same performance, the same mood, where no one is better or worse, but rather to create a society in which the principle of equal opportunities is really respected. And what about neuroenhanecement in children? If safe and guaranteed the principle of equal opportunities, should the State allow it too? Or should the Law intervene and forbid it in children? In fact, parents are constantly deciding on their children’s education, food, leisure activities, health, among many examples. How far should the Law in parental education intervene? Law forbiddens, for example, certain behaviours in children, even with parental consent, such as alcohol, driving, and smoking. One strong reason for the State to intervene and not allow its use is the danger to pervert parental relationship.39 As stated by Thomas Nagel, a controversial trait of Rawls Theory of Justice is its ‘anti-perfectionism’.40 We know how the ideal of perfection, the desire to improve, to overcome its limits is part of human nature. However, Rawls makes clear that this can be an anthropological or an ethical ideal, but not a political one or a State concern. The danger of perfectionist theories (Plato, Aristotle, Nietzsche) is to make ethics and law absolutely coincide, and so to impose on citizens a teleological vision of human nature, which they will be obliged to accomplish. What matters to Rawls, above all, is that all people are given the basic conditions to carry out their conception of good life. This ethical conception is private, and is somehow associated with perfectionism, because it is concerned with finding the possible means in society to accomplish personal dreams and achieve happiness. However, the ideal of perfection may coincide with some people’s ideal of life, but not others. Also the ideal of perfection would alter Rawl’s conception of the original position, since hardly all would undertake to develop certain ways of being and to cultivate certain tastes.41 As a consequence, 39. As Hank Greely sustains, parents would start to view «[…] their children more as a product to be manufactured, to parental specifications, than as a fully individual human being, to be cherished with all his or her quircks or flaws.» GREELY 2006: 260; SANDEL 2007: 47-57. 40. NAGEL 1973: 222. 41. RAWLS 1999: 286-287. Cognitive Neuroenhancement 167 it would no longer be possible to establish the principles of justice, since it immediately challenges Rawls first principle of justice, that is, the fundamental requirements of human freedom, and these can not be sacrificed for anything. Without equal respect for the most basic freedoms for all citizens, justice in society is right away compromised. The State should invest in social resources to increase chances of enhancing its citizens (culture), but this investment should never override their basic freedoms and needs.42 Against the principle of perfection, Rawls’ theory does not propose to achieve a human ideal, a model of human nature to be accomplished. Rawls’s goal is to ensure that justice is a virtue prior to all ethical principles, able to establish the most fundamental life principles and rules in society. However, recognizing that justice depends on respect for the basic freedoms of citizens (these are inviolable) and on the principle of fair opportunity is also to defend an ethical ideal of a person to be preserved and pursued. Rawls’s conception of a person is grounded on autonomy, the capacity to rationally create and pursue a life plan, and with sense of justice. That means the personal ability to evaluate the fairness of private plans in terms of its public accomplishment, in community. In the future, if the basic principles of security, autonomy and equality of opportunity are respected, cognitive neuroenhancement can be an ethical and just way of living well in society. CONCLUSIONS One of the strongest arguments against neuroenhancement is the belief in a very clear boundary between disease and health: clinical resources to treat diseases are legitimate, but to empower healthy people are not a priority or are even considered illegitimate. The paper tried to show that the definition of health is positive and holistic, so this proposal to solve the ethical and fairness problem of neuroempowerment is both reductive and false. Against this argument, it was 42. As Rawls sustains: «While justice as fairness allows that in a well-ordered society the values of excellence are recognized, the human perfections are to be pursued within the limits of the principle of free association. Persons join together to further their cultural and artistic interests in the same way that they form religious communities. They do not use the coercive apparatus of the state to win for themselves a greater liberty or larger distributive shares on the grounds that their activities are of more intrinsic value. Perfectionism is denied as a political principle.» RAWLS 1999: 289. 168 Sara Fernandes sustained that contemporary medicine, its notion of health and its application to the field of cosmetic surgery, indicate a clinical tendency to legitimize neuroenhancement. There were outlined some cultural roots of the human desire of neuroenhancement and it was sustained that playing with human emotions, especially awakening and exploring fears, is one of the ways to discredit science. 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