As the Olympics near, the question of performance-enhancing procedures for athletes gains social salience. MSNBC has run two articles recently on the ethics of performance enhancement, one by venerable mediagenic bioethicist Art Caplan, and the other addressing biotech advances that may allow new forms of enhancement.

The biotech article really caught my attention. It discusses the possibility of somatic-cell genetic engineering as a means of performance enhancement - perhaps to boost operation of erythropoietin-making genes (to increase oxygen-carrying capacity of the blood), or to provide other, unspecified advantages. According to the article, experts believe the scenarios are closer on the horizon than I had imagined:

In March of 2002, the World Anti-Doping Agency (WADA) . . . met with genetic scientists to ask if athletes and their handlers would soon be altering their very genomes in an effort to soup up their performance. Was the age of the genetically-enhanced athlete upon us?

The meeting resulted in a good deal of speculation and public fretting, both by pundits and by WADA. But much of that fretting, said experts in genetic science, was misplaced. Using genes to enhance athletic prowess was still far away.

The second meeting to assess the future of genetic tinkering in sport was held in December in Stockholm, but now, says Theodore Friedmann, one of the world’s leading experts on gene therapy to treat disease and the chairman of WADA’s gene-doping panel, “I’m not so sanguine as I was that this is far off in the future.” Scientists studying genetics, Friedmann reports, “often say they are approached frequently by athletes, trainers, entourage-type people asking what is available.”

Still, all that proves is that athletes are motivated. But is the technology really ready?

Probably not, but, says Larry Bowers, the senior managing director of technical and information resources for the United States Anti-Doping Agency (USADA), the sports world has its eye on the Beijing summer games. “By 2008 there may be tempting possibilities. That might be the time we really need to be more concerned.”

2008 sounds pretty damn close to me. Recognize, also, that there is at this time not one single somatic-cell genetic therapy in clinical use, even against seemingly-tractable conditions such as sickle-cell anemia or cystic fibrosis. The few therapies that have been tried have shown limited results and often came with horrendous side effects. If they are seriously talking about potential performance-enhancing technologies in less than two years - presumably procedures that have gotten far less research attention than have cures for genetic diseases - that suggests remarkable breakthroughs very close to completion. But whenever it happens, it will surely happen. The question is what to do about it.

For obvious reasons, genetic enhancements are being treated as a form of illegal “doping” - the “drugs” in question apparently being the poly-peptide products of engineered genes. The real parallel, of course, is the common theme of “tinkering” with the body to increase the performance available from the inborn “hardware” alone. If blood-doping or erythropoietin injections are illegal - using substances naturally occurring in the body, or even produced by that athlete’s own body - then it is not so far a stretch to suggest that taking advantage of proteins produced by and remaining within the body should also be illegal, where those proteins are the direct product of technological interventions far more intrusive than mere blood transfusion.

However, I think we are entering territory in which we are forced to split hairs more and more finely. What if - to take a hypothetical, and likely impossible, example - an athlete has a naturally-inherited genetic condition that produces a certain substance when and only when (as in the case of PKU) the athlete eats a certain diet, and this substance happens to be highly performance-enhancing? Would the athlete be prohibited from eating that diet? What if it was a very strange diet that no one would likely eat, and that has no nutritional benefit, other than in the case of possessing this enhancing allele - would the athlete then be allowed to engage in a practice that clearly serves only to provide a unique genetic benefit?

The MSNBC story recounts the history of Eero Mantyra, a Finn who owned Olympic cross-country skiiing in the 1960s; he had a genetic mutation of his erythropoietin gene that gave him a much higher-than-normal red cell count. No one questions that he was entitled to compete and win his medals; in fact, the mutation story laid to rest rumors that he had been blood-doping. But that is the oddest fact of all: he was entitled to compete with an abnormally high hematocrit resulting from a natural genetic mutation, but would have been severely punished for competing with the same hematocrit resulting from a transfusion of his own blood; now, apparently anyone else will be prohibited from competing after using genetic engineering to acquire the same genetic mutation Mantyra had, while presumably any of Mantyra’s descendants who have the mutation will still be allowed to compete as long as they inherited it “naturally”. Simultaneously, athletes who train at high altitudes to force their bodies to produce more red blood cells are allowed to compete, but simply injecting those blood cells into your body is illegal. The standard for “purity” seems to be not that you may not take advantage of biological characteristics outside the human norms, but rather that you may only compete with the biological characteristics you inherited (or acquire through training), not those that were acquired by “technology”.

This is an odd standard in two ways: first, it treats “technology” in some mythical, and false, fashion. The technology used in training top athletes, let alone in producing their equipment, is far more sophisticated and cutting-edge than that used in “blood doping”, which is an ordinary blood transfusion, or in some forms of chemical enhancement which use chemicals naturally occurring within the body. And some of that training technology is bodily invasive - scans, blood tests, internal monitoring devices - so the distinction cannot be between internal and external applications. Furthermore, training itself is intended to enhance the body, and training makes far more difference in an athlete’s performance than any enhancements do. (A highly-trained athlete can compete at the top level without enhancements, but a completely untrained person cannot compete at all even if given maximum enhancement therapies.) To think of “enhancements” as different from the other explicitly-enhancing practices - training, body building, special diets and supplements, artificial pressure and oxygen environments, and the like - is simply to indulge in an intuitionistic, largely emotional distinction between “natural” and “unnatural” that breaks down upon even cursory inspection.

The second problem with this “inherited characteristics” standard is that it seeks to oppose what the normal process of training and skill-development - practices that essentially define serious athletics - are explicitly intended to promote. The purpose of enhancement is identical to the purpose of the training and developmental practices that are accepted as legitimate: to improve performance. Most enhancement-limiting regulations in sports impose “leveling” limits - boundaries that give every competitor an “even playing field” to ensure that the contest is determined by skill on the field and not differences in basic “hardware”. (Examples include NASCAR “stock” performance definitions, balancing weights in horse races, and handicaps in golf games.) It is difficult to tune bodies to a stock performance standard, but focusing instead on the means by which performance is enhanced - declaring some means illegitimate and others legitimate, based on a wholly illusory distinction between “natural” and “technological”, when those means each seek exactly the same end - is an exercise in futility.

On a similar note, the goal of limiting enhancement - ensuring “fair play” - is itself illusory. The whole point to prohibiting enhancements is to prevent some players from obtaining “unfair advantage”. But at the top levels of international sport, there are no unfair advantages: every country has access to the same technologies and can provide them to its athletes if it chooses. (And most “enhancement” technologies used today - blood doping, artificial erythropoietin, and steroids - are trivially cheap anyway.) Athletes are also trained to near-peak personal performance levels. Competition then becomes a test to determine who has greater bodily gifts - whose “top end” is higher. But we place arbitrary limits on what means they can use to achieve that top end. Competition thus devolves to a test to determine whose top end can be raised higher using some, but not all, of the available enhancement techniques. But why is this interesting? What makes a distance race between one runner who was born at high altitude, another runner who moved to high altitude t0 train, and a third runner who happens to have a naturally high hematocrit resulting from an inborn genetic mutation, a viable and inspiring athletic competition, but the same race a dirty sham if it includes a fourth runner who injected the same amount of extra blood cells as the others enjoy “naturally”, or a fifth who used genetic engineering to achieve the same thing? (Note that it cannot be a question of rewarding “athletic spirit” or hard work - two of the first three athletes above achieved their blood-born advantages without any effort on their part, yet we still accept their achievements as legitimate, while excoriating those who used a blood transfusion or genetic engineering to achieve exactly the same bodily capacity. And the inborn mutation is - we’ll stipulate - genetically identical to the somatic-cell enhancement acquired through genetic engineering, but again one is acceptable and one is not. This is absurd.)

There are other possible objections to enhancement - it may encourage drug use by teen athletes; it will entice many hopeful athletes into dangerous practices, though only a few of them will enjoy successful competitive careers; it may indirectly encourage abuse of other drugs; perhaps others. But these are mostly regulatory issues, not really questions of competitive “appropriateness”.

Caplan takes a different approach in his moral objection:

My view is that it is wrong to use a drug to improve performance if that drug is dangerous, risky or unsafe. Since most drugs have very real risks, it is hard to justify allowing their use simply to go farther on your skis or get downhill faster on your skeleton.

(Note these are the only two sentences in his entire column-length article that address the moral question. Much of the rest is devoted to sled jokes.)

Now, obviously, Caplan can’t really mean what he says here: many drugs “improve performance” and they all carry risks. By his lights, it would be immoral to use any drug at any time (or at least any that “improves performance”). Even ordinary medical treatments for athletes’ illnesses “improve performance”, and surely those are legitimate. Obviously, he means “any drug that only improves performance in athletic competition, and serves no larger clinical purpose” - but he ought to say so. More importantly, he offers a one-sided test of moral righteousness: a drug is bad “if that drug is dangerous, risky, or unsafe” (I have no idea what the differences between those three things are - surely if a drug is any one of them it is all the others as well) - no matter what its benefits may be. This is even more absurd, and Caplan knows better. Here he argues like those who only list the risks of abortion or marijuana use, and then conclude they are obviously immoral because so many bad things come from them - without ever mentioning that the alternatives may be even more dangerous, or the benefits may be justificatory. Caplan, a highly respected ethicist, is not one of those people, but this is a bad piece of writing. It is not for him to say whether “simply . . . go[ing] farther on your skis” is a good enough reason for anyone else to choose to accept the risks of using a drug to do so. For some reason he abandons basic principles of proportionality and autonomy to propose a blanket ban on something he simply doesn’t like, used for purposes he simply doesn’t value - not the kind of thinking we expect of him.

This does bring us closer to the real issue at hand, though - not athletic competition itself, but body enhancement as a practice and a human enterprise. The idea of “going beyond” your “natural” endowments is distinctly off-putting to many people in particular contexts. There is now an entire movement dedicated to opposing body enhancement of certain kinds (while actual “body-modders” go about their business within their own community, largely ignored - or treated as unimaginable freaks - by the larger society). Like the distinction between “natural” and “non-natural” athletic performance enhancement, there are greatly arbitrary distinctions made between other kinds of enhancement as well (artificial breasts: good; artificial horns on the head: bad). I tend to think of the athletic enhancement debate as merely one instantiation of the building confrontation over bodily enhancement - and the role and purpose of medical science and medical practice - in general. Clearly, there is a great deal of confusion waiting to be cleared up.

Hat tip: AJOB/bioethics.net