Chapter 43 — Further Reading

Enhancement Outside the Clinic

A note before the list. This chapter's literature is unusual for this book in that most of it is not pharmacology. The pharmacological question — do these compounds do anything in healthy adults — is covered in Chapters 14 and 16 and their reading lists. What you need here comes from bioethics, from economics, and from the sociology of sport, and the most common failure in enhancement arguments is that people read only one of the three.

A standing caution. Almost every author below has a position, several hold positions irreconcilable with each other, and this book endorses none of them. Read at least one item from each side of any disagreement you care about. The books arguing for enhancement and the books arguing against it are equally worth your time, and reading only the ones you already agree with is exactly the failure mode Chapter 6 described in a different register.

Tier 1 — Start here

Sandel, M. The Case Against Perfection: Ethics in the Age of Genetic Engineering. Harvard University Press, 2007. The most readable statement of the case against enhancement, and unusual in that its central objection is not about safety or fairness at all — it is about what enhancement expresses regarding our relationship to gifts we did not earn. Short. You will finish it in an evening, and you should read it even if you expect to disagree, because it is the argument most people gesture at without being able to state.

Buchanan, A. Better Than Human: The Promise and Perils of Enhancing Ourselves. Oxford University Press, 2011. The counterweight, written by a philosopher who takes the objections seriously and answers them one at a time. Read this second, immediately after Sandel, as a matched pair. The argument that enhancement is continuous with things we already accept — education, vaccination, eyeglasses — is made here about as well as it can be.

Greely, H., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., Campbell, P., & Farah, M. J. "Towards responsible use of cognitive-enhancing drugs by the healthy." Nature, 2008. A short, much-cited commentary that attempts to set out conditions for permissible enhancement rather than a verdict on it. It is the most direct published ancestor of the five-condition approach in §43.9, and comparing its conditions to this chapter's is a genuinely useful exercise — note especially what it says and does not say about coercion.

World Anti-Doping Agency, the World Anti-Doping Code and the current Prohibited List. Freely available from the agency. Read the criteria for adding a substance rather than the list itself — that is where the reasoning lives, and it is more interesting than most people expect. Chapter 38 covers this material in full; skim it here only to see what an explicit, published, enforced answer looks like when someone has actually had to write one down.

Tier 2 — Going deeper

President's Council on Bioethics. Beyond Therapy: Biotechnology and the Pursuit of Happiness. 2003. A book-length government report that is far better written than that description suggests. Its treatment of "superior performance" is directly on this chapter's subject, and its willingness to sit in ambivalence rather than resolve is a model for how to write about this honestly. Dated in its science, undated in its questions.

Savulescu, J., & Bostrom, N. (eds.). Human Enhancement. Oxford University Press, 2009. An edited collection that puts opposing positions in the same volume. The most efficient way to encounter the full range of the debate, and the chapters disagree with each other productively rather than politely.

Murray, T. H. Good Sport: Why Our Games Matter — And How Doping Undermines Them. Oxford University Press, 2018. Written by someone with long involvement in anti-doping policy, and the strongest available defense of why sport drew the line where it did. Pair it with the next item.

Kayser, B., Mauron, A., & Miah, A. "Current anti-doping policy: a critical appraisal." BMC Medical Ethics, 2007. The other side: an argument that anti-doping policy's costs exceed its benefits and that a supervised alternative would be safer. This is the level-playing-field argument made carefully by people who know the system. Read it directly after Murray, and notice how much of the disagreement is empirical and how much is not.

Elliott, C. Better Than Well: American Medicine Meets the American Dream. Norton, 2003. On the cultural machinery that turns a treatment into an aspiration, and on why the therapy–enhancement line keeps moving. Essential background for Chapters 41 and 42 as well as this one.

Daniels, N. "Normal functioning and the treatment-enhancement distinction." Cambridge Quarterly of Healthcare Ethics, 2000. The canonical technical treatment of where the line falls and why it is harder to draw than it looks. Short, dense, and worth the effort if the §43.1 distinction feels too tidy to you — it should.

Schelling, T. Micromotives and Macrobehavior. Norton, 1978. Not about enhancement at all, and the single most useful book on this list for understanding §43.5. Schelling's subject is exactly the phenomenon this chapter describes: how individually sensible choices aggregate into outcomes nobody chose. If the five-step structure felt intuitive but you could not say why it generalizes, this is the book that explains it.

Tier 3 — Primary sources and the technical foundations

Liu, H., et al. "Systematic review: the effects of growth hormone on athletic performance." Annals of Internal Medicine, 2008. The empirical anchor under §43.3's ❌ rating and under Chapter 16's mass without function finding. Read the outcomes table rather than the abstract, and note specifically which endpoints were measured and which were not. This is the paper to have in mind whenever someone treats a body-composition change as evidence of a performance change.

Hirsch, F. Social Limits to Growth. Harvard University Press, 1976. The origin of the concept of positional goods, and the source of the insight that some benefits cannot be extended to everyone because their value consists in not everyone having them. Dry, and foundational to §43.2 and §43.5.

Frank, R. H. Choosing the Right Pond: Human Behavior and the Quest for Status. Oxford University Press, 1985. The development of positional-good reasoning into a general account of competitive behavior, including the arms-race dynamics that §43.5 describes. Frank's later work extends the argument to policy.

Olson, M. The Logic of Collective Action. Harvard University Press, 1965. The classic statement of why groups fail to achieve outcomes that would benefit all their members. The theoretical foundation of the claim that exhortation cannot solve the coercion problem.

Ostrom, E. Governing the Commons. Cambridge University Press, 1990. And the necessary corrective to Olson: an empirical demonstration that collective action problems are sometimes solved, by specific institutional arrangements with identifiable features. If you finished §43.9 feeling that condition 3 is hopeless, this is the book that complicates that conclusion — read it asking which of Ostrom's design principles could conceivably apply to a competitive labor market.

Pigou, A. C. The Economics of Welfare. Macmillan, 1920. And Coase, R. "The Problem of Social Cost." Journal of Law and Economics, 1960. The two foundational treatments of externalities, and between them the whole of §43.8's argument about why risk that falls on non-decision-makers is systematically under-weighted. Coase's paper is also the classic statement of when the problem can be bargained away and when it cannot, which is directly relevant to whether risk transfer is achievable here.

Faden, R., & Beauchamp, T. A History and Theory of Informed Consent. Oxford University Press, 1986. The definitive treatment of what consent requires and when it fails. The material on voluntariness and controlling influences is the technical foundation for §43.4's claim that "voluntary" means something different inside a hierarchy.

Beauchamp, T., & Childress, J. Principles of Biomedical Ethics. Oxford University Press, current edition. The standard framework. Relevant here mainly for what it assumes: it is built around a clinical relationship, which is precisely the thing §43.1 says enhancement removes. Reading it with that absence in mind is more instructive than reading it straight.

If you only do one thing

Read Sandel and Buchanan back to back — the two Tier 1 books — and then write one page on where you actually stand.

Not a summary of either. Your own position, in your own words, structured as follows: the strongest version of the view you reject, stated fairly enough that someone holding it would accept your statement of it; then your own view; then the strongest objection to your own view that you cannot answer.

Two pieces of guidance on doing this well.

Mark every sentence in your page as either a factual claim or a value claim. You will find the proportion surprising, and you will find at least one sentence you cannot classify. That sentence is where your real work is.

And notice whether your position changes when the efficacy evidence changes. If you would hold the same view whether these compounds work or not, your position is a values position and you should say so — which is legitimate, and considerably more honest than the alternative. If it would change, then you have an empirical dependency, and you now know exactly which finding to watch for.

Either answer is respectable. Not knowing which one you have is the thing worth fixing.