Neuroethics beyond Normal

Abstract

An integrated and principled neuroethics offers ethical guidelines able to transcend conventional and medical reliance on normality standards. Elsewhere we have proposed four principles for wise guidance on human transformations. Principles like these are already urgently needed, as bio- and cyberenhancements are rapidly emerging. Context matters. Neither "treatments" nor "enhancements" are objectively identifiable apart from performance expectations, social contexts, and civic orders. Lessons learned from disability studies about enablement and inclusion suggest a fresh way to categorize modifications to the body and its performance. The term "enhancement" should be broken apart to permit recognition of enablements and augmentations, and kinds of radical augmentation for specialized performance. Augmentations affecting the self, self-worth, and self-identity of persons require heightened ethical scrutiny. Reversibility becomes the core problem, not the easy answer, as augmented persons may not cooperate with either decommissioning or displacement into unaccommodating societies. We conclude by indicating how our four principles of self-creativity, nonobsolescence, empowerment, and citizenship establish a neuroethics beyond normal that is better prepared for a future in which humans and their societies are going so far beyond normal.

Full text

Cambridge Quarterly of Healthcare Ethics (2016), 25 , 121 – 140 .
© Cambridge University Press 2016.
doi:10.1017/S0963180115000377
121
Neuroethics Now
Neuroethics Now welcomes articles addressing the ethical application
of neuroscience in research and patient care, as well as its impact on
society.
Neuroethics beyond Normal
Performance Enablement and Self-Transformative Technologies
JOHN R. SHOOK and JAMES GIORDANO
Abstract: An integrated and principled neuroethics offers ethical guidelines able to tran-
scend conventional and medical reliance on normality standards. Elsewhere we have pro-
posed four principles for wise guidance on human transformations. Principles like these
are already urgently needed, as bio- and cyberenhancements are rapidly emerging. Context
matters. Neither “treatments” nor “enhancements” are objectively identifi able apart from
performance expectations, social contexts, and civic orders. Lessons learned from disability
studies about enablement and inclusion suggest a fresh way to categorize modifi cations to
the body and its performance. The term “enhancement” should be broken apart to permit
recognition of enablements and augmentations, and kinds of radical augmentation for spe-
cialized performance. Augmentations affecting the self, self-worth, and self-identity of per-
sons require heightened ethical scrutiny. Reversibility becomes the core problem, not the
easy answer, as augmented persons may not cooperate with either decommissioning or
displacement into unaccommodating societies. We conclude by indicating how our four
principles of self-creativity, nonobsolescence, empowerment, and citizenship establish a
neuroethics beyond normal that is better prepared for a future in which humans and their
societies are going so far beyond normal.
Keywords: neuroethics ; principles of ethics ; bioenhancement ; performance ; enablement ;
self-identity ; autonomy
Entwined Projects and Four
Principles
As a discipline, neuroethics encom-
passes two broad projects. It considers
the implications of brain and behavioral
research for understanding the cogni-
tive processes and psychology involved
in, and perhaps responsible for, moral
judgments and conduct. Neuroethics
also addresses and evaluates issues,
questions, problems, and trajectories
of proposed neuroscientifi c and neu-
rotechnological interventions on sub-
jects, by selecting and applying moral
guidelines.
1 , 2 , 3
Those guidelines may
be borrowed from older ethical resources
largely untouched by current moral psy-
chology and neurology. Alternatively,
neuroethics could invest its dual-mode
inheritance into the integration of up-to-
date science for developing an improved
ethics. We assert that neuroethics can
and should formulate and defend a
coherent set of moral priorities, includ-
ing in its deliberations discoveries about
ways that humanity practices morality
and thinks about moral values and
norms. Neuroethics won’t be daunted
by dichotomies of a logic untainted by
science. Those isolating their “oughts”

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122
from what humanity “is” will be left
behind, idolizing a humanity that was.
We propose that, in order to make
distinctive ethical recommendations of
its own, neuroethics must do more than
endorse commonly encountered moral
priorities or philosophically venerable
ethical principles. Whereas any neuro-
ethicist is quite at liberty to recommend
local social morals, a culture’s morality,
or some philosophy’s ethics for resolv-
ing moral concerns or deeper ethical con-
fl icts, those recommendations wouldn’t
automatically be those of neuroethics
itself. Genuinely neuroethical recom-
mendations should be guided by authen-
tically neuroethical deliberations. The
need for those deliberations has become
urgent. Essential matters on which famil-
iar legal rules and ethical principles are
predicated—the nature of the human
“body,” the “person” worthy of respect,
and the “self” in its autonomy—are no
longer fi xed landmarks for drawing rigid
baselines.
The fi eld of neuroethics must assem-
ble fresh resources for surveying and
traversing such a dramatically chang-
ing landscape. An integrated and prin-
cipled neuroethics would thoughtfully
offer ethical guidelines not only to
address those specifi c instances in which
neuroscience and neurotechnology are
directly involved but also, more gener-
ally, to approach and guide how scien-
tifi c and technological progress is taking
humanity to new frontiers that raise
truly novel ethical concerns. Neuroethics
in theory and practice has no choice but
to go beyond normal.
In this light, we have recommended
four guidelines to provoke the inaugu-
ration of a principled neuroethics.
4
They
are enlargements on the bioethical prin-
ciplism of Beauchamp and Childress.
5
They give more explicit regard to indi-
vidual transformations prompted and
achieved by the brain sciences, and to
the civic contexts in which bioenhanced
and neurotechnologically transformed
people will reside. Our principles are as
follows:
1) Self-creativity: The right of persons
to re-create themselves to enrich
their lives
2) Nonobsolescence: The duty to avoid
the creation of obsolete people
3) Empowerment: The duty to increase
the capabilities of people to live
autonomous and fulfi lling lives
4) Citizenship: The duty to promote
free, equal, law-abiding, and par-
ticipatory citizenship
These ethical guidelines are recom-
mended not as maximum limits but
only as minimum expectations. Societies
should try to mutually adjust and exceed
them, each in their own way. Respect for
cultural diversity and global pluralism
is embedded and refl ected in these prin-
ciples. The world’s peoples pursue con-
ceptions of the good life, guide their
societies as best they can, and gradually
experiment with novel ways of living.
A society systematically violating any
of these four principles does not respect
those meaningful pursuits and deserves
moral disapproval. To be relevant on
an international scale, neuroethics must
pay due heed to transcultural con-
texts, while offering more than moral
relativism.
6
A neuroethics fragmented by pre-
sumptive normalities, folk psycholo-
gies, social conventions, national laws,
or dogmatic moral systems won’t suffi -
ciently enable preparation for what lies
ahead. No single country or league of
countries may be able to fully control
the coming modifi cations to our species,
as humanity embarks on experimental
diversifi cations to the brain, body, and
genome on an unprecedented scale.
7
If
we expect global deliberations to be
cohesive, then neuroethics must become
integrated. The following sections discuss

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123
limitations to medical models of normal-
ity and current framings of enhancement,
followed by an improved schema for
comprehending performance enhance-
ments and potential enablements; fi nally,
we connect the utility of that schema with
emerging neuroethical issues and the
four neuroethical principles to deal with
them.
The Natural and the Normal
Arguments based on some established
notion of what a human being “natu-
rally” should be, what a human being
“normally” should pursue, or what
a human being “necessarily” should
deserve shouldn’t receive presumptive
weight in a principled neuroethics.
Neuroethics, unlike traditional medical
ethics, is fundamentally not about health
or medicine, nor is it essentially about
making people normal or better. Rather,
it must start from ample recognition
of the ways that people can be similar
and/or different from one another.
Neuroethics must concern itself with any
potential modifi cation to and diversifi -
cation of the body, brain, and embodied
“self” that may become achievable.
This due concern has been commonly
characterized as the issue of “human
enhancement” or “bioenhancement.”
8 , 9 , 10
Yet neuroethics is already moving
beyond the social and legal framework
that shaped medical ethics and pre-
liminary conceptions of enhancement.
Technically, translational and dual-use
research extends possibilities for organic
modifi cation far beyond medicine’s pur-
view. On the ethical side, two features of
traditional medical ethics must be tran-
scended: presumptions about what con-
stitutes the normal healthy body and the
concept of a direct line from therapy on
to enhancement engendered by those
presumptions. The question of transhu-
manism points to a third ethical consid-
eration: besides therapeutic restorations
of health and enhancing human capaci-
ties above some normal level, bioen-
gineering and cybernetics look ahead
to exceeding standard human traits
and capacities entirely. How transhu-
manism’s apologetics, or posthumanist
visions, can surpass simplistic notions
about enhancement is a separate mat-
ter.
11 , 12
Still, neuroethics can—and argu-
ably should—be valid and valuable to
the discourse.
13 , 14
Trans- and posthumanist speculations
aside, a future-oriented and civic-minded
neuroethics is urgently needed at pres-
ent. Of course, the accomplishments
of medical ethics are not to be lightly
discarded. Medical ethics defended
patients’ rights and healthcare provid-
ers’ duties and addressed issues from
artifi cial conception and abortion to end-
of-life care and euthanasia. However,
medical ethics largely relies on the dom-
inant cultural norms and prevailing legal
principles of the home countries of
leading medical ethicists. By demand-
ing consistency with U.S. laws and con-
stitutional rights, for example, American
medical ethics developed guidelines for
medical conduct in institutional settings
such as clinics, hospitals, and research
laboratories.
15
Medical ethics has also enlarged its
purview beyond domestic accountabil-
ity, while remaining indebted to Western
medicine’s normative notions of the
“moral individual,” what counts as
“standard health,” and concerns for
the “autonomous patient” (MISHAP).
16
Despite repeated warnings from numer-
ous voices over past decades, much of
the work in and of medical ethics, like
that of medicine, has rather uncritically
and univocally spoken of such things
as “the human being,” “the healthy
body,” “the normal capacities,” “the
person,” and “the competent agent,” as
if these terms refer to readily identifi -
able and certifi able matters. Medicine
has acquired knowledge about how the

Neuroethics Now
124
human genetic code is supposed to con-
struct the human body, how the human
body normally works, and how the
human body is affl icted by de formities,
dis eases, and de mentias. At its core,
medicine treats deviations from what
is considered to be proper form, desir-
able ease, and right mentality and in so
doing typically relies on its normative
conceptions of what the normal, healthy
human being is supposed to be.
Some may still presume that the
“normal” human body treated by most
of medicine is grounded in natural biol-
ogy alone, outside of any sociocultural
framework; but we need not again sur-
vey the demonstrable ways that medi-
cine has been directed and misdirected
by cultural contexts. Estimating species-
typical organic functioning is one thing;
judging proper human functioning is
quite another. The “typical” human on
the planet today, at the median among
7 billion plus inhabitants, does not nec-
essarily correspond with who counts
as a healthy patient in a local doctor’s
offi ce.
The concept of enhancement illus-
trates how familiar framings leave inad-
equate categorizations in their wake.
The presumption of medical categories
and cultural norms by societies doing
medical ethics explains how medicine
and medical ethics generated the sup-
posedly exhaustive division of thera-
pies and enhancements. Medicine can
depict health modifi cations on a lin-
ear continuum by consulting available
ideas about the proper features and
functions of what is construed to be a
normal healthy body. Where a therapy is
(roughly) taken to be the modifi cation
of physiological/psychological func-
tioning toward some standard for nor-
mal health, an enhancement could then
be regarded as improved functioning
beyond that standard. From a naïve
medical perspective, there can be a
neat divide separating therapy from
enhancement—an enhancement is what-
ever isn’t needed as a therapy—so
together they exhaust the possibilities
across a continuously linear range.
Achieving descriptive simplicity is thus
matched by adoption of a conveniently
simplistic normativity. Just as labeling
an intervention as a “therapy” carries
connotations of value and desirability,
the label of “enhancement” sounds
worthy unless and until proven other-
wise. Who could be so heartless and
impractical as to deny humanity an
opportunity for real improvement?
The potential applications of new bio-
technologies are exposing severe limi-
tations to this simplistic continuum and
its underlying congeniality with medi-
cal notions of normality and swift judg-
ments of practicality. In the years and
decades ahead, neuroscience and neu-
rotechnology will enable doing things
to bodies and brains that have little or
nothing to do with common concep-
tions of normality. In this global age,
as new technologies are developed and
employed in pluralistic, international
contexts, and as access to information
accelerates on worldwide scales, we no
longer have the luxury of conducting
medical ethics or neuroethics as if it
comes down to disagreements among
ethical systems or political camps. The
settled judgments of medical ethics from
past decades will be of little casuistic
utility for guiding radical new applica-
tions of biotechnology that do not con-
form to familiar ethical, cultural, or even
biological paradigms.
Why Isn’t Enhancement Enough?
Erik Parens expressed a verdict about
“enhancement” that has been reached
by many: “some participants think the
term enhancement is so freighted with
erroneous assumptions and so ripe for
abuse that we ought not even to use
it. My sense is that if we didn’t use

Neuroethics Now
125
enhancement, we would end up with
another term with similar problems.”
17
This sentiment has been shared by pro-
ponents, skeptics, and pessimists about
enhancement, including those working
in neuroethics.
18 , 19 , 20 , 21 , 22
Using terms
laden with ambiguity is a problem.
We believe that, instead of replacing
one poor term by another problematic
term, it would be better to develop an
improved, more specifi cally accurate lex-
icon, at least to serve those fi elds involv-
ing scientifi c research.
Unlike the medical term “therapy,”
which has developed and survived
as a useful concept with fairly well-
understood applications, “enhance-
ment” is routinely criticized for being
unclear as to what interventions (should)
properly count. What about those med-
ical or nonmedical modifi cations that
do not categorically fi t well with either
therapy or enhancement? Why should
the positive value connotations attached
to therapy also be attached to enhance-
ment, especially when the full value
of an enhancement is questionable?
Furthermore, could an enhancement
have intrinsic merit regardless of social
context, and independent of societal
judgment?
A primary diffi culty is the fact that
an identical treatment may be a therapy
for one person and an enhancement
for another, depending on each person’s
situation and context.
23
Impressive ther-
apies can rehabilitate performance above
the unmodifi ed population’s norms,
lending them the appearance of being
an enhancement.
24 , 25
Medical interven-
tions ordinarily designed for effecting
therapy can produce results looking
like enhancements if given to healthy
people.
26
Treatments for repairing inju-
ries can indeed improve the functioning
of uninjured people. For example, some
baseball players perceive the “Tommy
John” surgery (UCL elbow reconstruc-
tion), if performed before elbow problems
arise, to be an acceptable performance
enhancer.
27
Engaging a standard that defi nes
treatments as interventions rendered to
(attempt to) return some aspect of indi-
viduals’ biology or performance to nor-
mal, and that defi nes enhancements as
any intervention rendered to individu-
als with normal biology and/or perfor-
mance (so as to augment their structure
or function), is one approach to creating
and discerning categories of interven-
tion.
28
But we opine that this, too, is not
without issues. Letting the biological
norm of the “healthy” person serve to
demarcate therapies from enhancements
hides ineradicable puzzles.
Consider a medical modifi cation of
the ear to improve the range and inten-
sity of hearing. Before describing that
modifi cation done to someone as an
enhancement, must we fi rst ascertain
its proper therapeutic use? An adult
without hearing from birth could choose
that modifi cation to gain hearing. There
is no need to fi rst label that person
unhealthy or disabled, so that receiving
this modifi cation can count as a ther-
apy.
29 , 30
Classifying some people as dis-
abled just so other people can appear
enhanced cannot be acceptable. The term
“enhancement” carries connotations
of above-normal functioning, which is
precisely the issue: who are the below-
normal people? Letting enhancement be
what isn’t regarded as therapy isn’t fully
workable. Relying too heavily on medi-
cal diagnoses permits the unacceptable
notion that an enhancement could be
objectively assigned without considering
either the recipient’s specifi c situation or
the wider social environment.
This is a narrative trap to be avoided.
Yes, therapies are good, but that can’t
mean that enhancements are automati-
cally good, or assuredly better than ther-
apies. Enhancing something is not the
same thing as improving it. The mean-
ing of “enhance” can point to a simple

Neuroethics Now
126
quantitative increase according to some
measurable dimension. It also can indi-
cate adding value where none had
existed. Or it could indicate the improve-
ment of an already present value. Does
an enhancement add a capacity to a
person? Would it simply strengthen a
capacity already possessed? Or could
some enhancements be achieved by
diminishing or even eliminating capac-
ities? If an enhancement doesn’t reach
toward an ideal of human excellence,
can it still be an enhancement for some
personally idiosyncratic dream? What
about the addition of capacities that
no other human has ever possessed?
As a perusal of the literature will reveal,
assigning such meaning(s) to the term
“enhancement” is quite prevalent.
Questions have been raised through
deeper analysis pointing to a third clas-
sifi cation beyond therapy and enhance-
ment.
31 , 32 , 33 , 34 , 35 , 36
Enhancements adding
planned or unplanned capacities never
acquired by the species need special rec-
ognition. The real-world consequences
of extreme enhancements cannot be per-
fectly predicted. What about enhance-
ments responsible for other anticipated,
or unanticipated, changes to function?
One valuable aspect of an enhancement
may not outweigh other deleterious
effects. Does “enhancement” refer to just
the specifi c intended improvement, or
should the overall impact be weighed?
Furthermore, an enhancement for a
certain capacity never guarantees that
the envisioned activities are reliably
achieved. Evaluations unavoidably con-
tain risk assessments here. An enhance-
ment may (help to) facilitate a desired
activity, but it may not suffi ce depend-
ing on varying conditions. Is an unreli-
able, less-than-fully-effective, or useless
enhancement actually an enhancement?
Judging enhancement may involve
recognizing and appreciating wider
social contexts, as well as individuals’
personal situations. If enhancement
should at least involve an above-normal
capacity, does one’s enhancement van-
ish if many other people acquire simi-
lar modifi cations, shifting the mean
or median ever higher? Alternatively,
if many people get different capacities
enhanced, permitting them to exceed their
own performance from a prior enhance-
ment, does it remain an enhancement?
Another scenario involves competitive
circumstances, in which the enhance-
ments of others could negate those
advantages that one had once gained
through an enhancement. The readi-
ness of society to deal with enhanced
persons appears to be a major variable
determining the status of enhancements
at large. (For musings on this theme,
see Dan Williams’s science fi ction novel
Amped ).
Ultimately, social norms are power-
ful forces. The standards of normality
by which enhancements are measured
could also fi nd a modifi cation strangely
deviant or just too weird. The social
environment includes moral standards
as well. Should the classifi cation of
enhancement be morality neutral, or
must a genuine enhancement respect
prevailing morals? What about higher-
level principles, such as the welfare of
society or political equality?
Performance Enhancement Options
Among philosophies informed by sci-
ence, pragmatism stands out for its
facility to address complex behavior-
organism-environment systems. Prag-
matism denies a rigid subject-object
dichotomy and the Cartesian self, per-
mitting continuities and integrations
among mental processes, bodily con-
trol, tool use, conducting activities,
and social interaction.
37 , 38
As neuro-
philosophy continues to absorb les-
sons from the cognitive and neural
sciences, a pragmatist neurophiloso-
phy has emerged at that convergence

Neuroethics Now
127
of insights into the embodied, enactive,
purposive, and cooperative nature of
all cognition.
39 , 40
In this view, neither treatments nor
enhancements could be objectively iden-
tifi able apart from human interactions
and social expectations. Additionally,
the signifi cance of human interactions
cannot be separated from broader social
expectations about those interactions.
People use social cognition to manage
dynamic interactions for group pur-
poses. Isolating and insulating mental
states from their generation and appli-
cation in the course of dealing with
local environs and social relations can
lead to erroneous characterizations of
consciousness and conduct. Isolating
the self also allows the assignment
of responsibility to this self alone.
Forgetting that meaningful action always
happens within (partially) cooperat-
ing environs has long distorted philo-
sophical psychology and contorted
modern ethics.
In short, thinking and doing are fused
and co-responsive. By attending to
conduct within its contexts, the proper
fi eld of inquiry may be captured by the
term “performance.” Bio-psychosocial
dimensions of performance are essen-
tial. In this light, we offer the basic ABCs
of performance. Five dimensions seem
to be primary:
performance (ABCDE) = accomplish-
ing trained activity (A) by using
bodily control (B) for enacting tooled
capacities (C), within a environing
domain (D) while coordinating with
ensembles of others (E).
For example, the performance of driv-
ing a car equals operating the vehicle
safely using rapid-response habits and
enhanced visual information, on pub-
lic roads surrounded by other drivers,
cyclists, and, periodically, pedestrians.
Therefore,
nonperformance = poor accomplish-
ment due any substandard A, B, C, D,
and/or E.
A vehicular mishap may be due to lack
of proper training, lack of bodily con-
trol to manage driving, lack of tools to
convey enough information, bad roads,
and other poor drivers and/or cyclists,
and/or careless pedestrians.
The circumstances in which most
people can expect their actual tooled
capacities to permit the performance
of “ordinary” living in society usually
foster such capacities that are widely
deemed to be normal. What feels
normal, according to most people,
appears to require no explanation.
A person’s nonperformance can usu-
ally be “explained” only by that per-
son’s poor bodily control or lack of
trained capacities. If bodily control and
training seem adequate, then the non-
performance is subsequently attributed
to a lack of tooling. If those all seem
to be adequate, and because social
domains and ensembles are still avail-
able givens on this limited view, fault-
ing the individual nonperformer now
seems easiest, perhaps for failure of
character or due to deviant impulses.
This nonperformer is hence (personally)
blamed for thwarting his or her bodily
control B, disdaining activity A, or dis-
liking domain D; ergo, this person must
be BAD. However, so long as suffi cient
training, ensembles, and tooling (STET)
would produce performance, the indi-
vidual needn’t have to change, and
one’s personal body and character aren’t
suspect.
If the nonperformer has bodily con-
trol diffi culties, it may be that physi-
ological adjustments, improvements
in assistive technology, and/or revised
training may bring about capacities per-
mitting the desired activity.
41
Emerging
technologies are eroding the distinc-
tion between upgraded tooling and

Neuroethics Now
128
physiological adjustment. Bionic pros-
thetics supply a good example.
42
When
a prosthetic hand is integrated with
modifi ed biomechanical and neuro-
logical structures of the arm so thor-
oughly that no clear line separates the
biological from the artifi cial, the body-
tool dichotomy breaks down. Brain-
computer interfaces may reach the
same degree of melded intimacy.
43
Neuropragmatism wouldn’t endorse
a fi rm dichotomy between tool and
body under ordinary circumstances
and couldn’t invent one for such pros-
thetics. We’ve learned to apply volun-
tary control over body parts to affect
our surroundings, and the brain read-
ily extends that felt control through
long-familiar tools. Tools that become
a physical part of us will become a
mental part of us.
However, prior to medicine’s access
to these emerging technologies, the
body-tool distinction was upheld, and
medicine focused on organic modifi ca-
tions alone to deal with illnesses and
injuries. Supplemented by orthotics
(retooling) and rehabilitation (retrain-
ing), medicine could stay attuned to
adjustments of physical and psycho-
logical functioning to remedy impair-
ments.
44
However, medicine required
standards for physiological functioning
to set treatment goals. The normal human
body was systematically defi ned with-
out explicit reference to any accessible
tooling or training, or any hospitable
environs or ensemble. That resulted in
high-functioning and successful people
tacitly presuming that their own physi-
ological condition was entirely normal,
and that this normality should be the
standard of normality for all of human-
ity. What counted as the human body
was determined by relatively abnormal
individuals—specifi cally, privileged peo-
ple who were not representative of the
human population. Medical psychology
was likewise prone to accepting the
psychological traits of elites as the stan-
dard of normal cognition and character.
With such privileged normality in
place, medical treatments could be char-
acterized in isolation from consider-
ations about the applied techniques of
tooling or training, or changes to the
social settings of places and persons.
Candidates for treatment are therefore
not merely nonperformers but instead
are labeled as dis abled for everyday
activities. So long as activity standards
are set without regard for technique
or society, disablement can remain an
individual matter. Reductive medicine
would permit all treatments producing
results beyond population normality to
be confusingly classifi ed as enhance-
ments. Worse, this reductivism obtains
that identifying those with enhance-
ments requires defi ning who is normal
and, in so doing, who is disabled. We
believe that surely there is another way.
Identifying the enhancements of some
mustn’t depend on unfairly discrimi-
nating against others.
45 , 46
Judging the
ethics of enhancement cannot—nor
should not—be a neutral matter. Ethical
systems supporting enhancement may
themselves harbor biases favoring what
counts as normal in society.
47
Opponents to reductive disability have
exposed common prejudices, identifi ed
structural obstacles, and faulted societal
discrimination.
48 , 49 , 50 , 51 , 52
Better medical
treatments ensuring performance capa-
bilities are indeed desirable, and design-
ing task responsibilities and supportive
environs appropriate to those capabili-
ties is civically justifi able.
53 , 54 , 55 , 56 , 57
What must be avoided is an ideological
standoff due to a simplistic x = y + z
type formula, wherein performance
equals individual practices in social set-
tings. By assuming that one factor is
static and treating the other as the vari-
able, performance becomes either the
entire responsibility of the individual
or entirely the responsibility of society.

Neuroethics Now
129
A pragmatist approach appreciates
context more seriously, ensuring that
all interactive factors are—and stay—
involved.
Performance in Context: Considering
Enablement
We may provisionally apply the term
“therapy” to a restorative or even
regenerative treatment administered to
an individual to affect an impairment.
A therapeutic plan should be as inte-
grative and holistic as possible.
58 , 59
“Enhancement” cannot be defi ned sim-
ply as nontherapeutic or parathera-
peutic treatment. Avoiding medical
reductionism and reductive disability
requires even greater attention to the
surrounding medical and social context
for evaluations of performance and non-
performance. Taking key factors into
account, let us reconsider the factors of
both technique (tools and training) and
society (environs and ensembles) more
fully.
Let “rehabilitation” stand for the resto-
ration of the capacities needed for ade-
quate performance through therapy plus
added tools and training.
60 , 61
The goal of
“enablement” additionally expects that
the coordination of these three factors
within rehabilitation should be modu-
lated to produce the envisioned perfor-
mances to be undertaken in society.
62 , 63 , 64
Enablement adjusts changeable physiol-
ogy plus technique within the given situ-
ation of generic (socially common and
constant) activities. Enablement doesn’t
demand alterations to the activity domain
beyond basic accessibility, nor does it
demand oversight of the ensemble of
people sharing in the planned activities.
By taking the environs and ensembles
as givens, enablement expects valu-
able techniques to help the individual
conform to given social conditions to
display capabilities. For example, enable-
ment trains a student to use an electronic
device for recording classroom lectures,
but it doesn’t require that instruction
no longer be delivered in the form of
spoken lectures. Majority convenience
and traditional methods prevail. Such
majority convenience is still the case
with accommodation, which coordinates
rehabilitation with modest changes to the
local environs for generic activities, such
as workplace positions. “Reasonable”
accommodation typically leaves core
activity functions unaltered, activity part-
ners unaffected, and activity environs
largely unchanged.
65
More dramatic accommodation
requires inclusion. The ideal of inclu-
sion places heavy responsibility on
environs and coparticipants to guaran-
tee participatory activity and relies on
rehabilitation as needed. The priority is
joint participation, not just individual
enablement.
66 , 67
Activities are planned
that ensure each person’s effective
performance with coparticipants (who
themselves may have performance
adjustments), undertaken in redesigned
environs that facilitate everyone’s suc-
cess. The ideal of inclusivity aims at full
and equal participation to the level that
each person can reach, without dis-
criminatory barriers obstructing com-
prehensive integrated status. However,
this venerable tradition, or issues of
majority inconvenience, can no longer
provide acceptable excuses for falling
short of inclusivity.
What, then, would be the neuroeth-
ical position with respect to the goals
of this type of inclusion theory? As
a civic and political ideal, inclusion
theory may seem distant from the
purview of neuroethics. However, a
principled neuroethics is relevant to
considering the sorts of enhancements
that involve self-transformative mod-
ifi cations. There are many reasons to
try to restore some level of normality,
and there will be reasons to attempt
exceeding some standard or another

Neuroethics Now
130
of normality. How should neuroethics
handle attempts to go beyond normal?
Therapy, Enhancement, and
Augmentation
Generic enablement restores perfor-
mance of the common activities found
across society. But not all activities are
generic. Specialized activities, to be
strenuously performed under unusual
environing conditions with only certain
coparticipants, are quite another matter.
Many specialized activities are accom-
plished with extra tools and training
alone. We may label preparation of any
person for specialized activities that
includes physiological and/or psycho-
logical modifi cations as the “specialized
enablement” of that person.
In the future, radically novel technol-
ogies will permit specialized enable-
ments to go beyond normal—in two
different senses of “normal.” In one
sense, normality applies to human
functioning commonly found in the
human population. Is a person’s func-
tioning better or worse compared to the
average functioning found in that pop-
ulation? Another sense of normality
applies to functioning that is rarely or
never found in the human population.
Is a person’s functioning quite different
from what the human population can
do? This distinction gives rise to two
different senses of beyond-normal func-
tioning: is something a person can do
abnormal because most others do it less
well, or is it abnormal because humans
don’t (yet) do it at all?
In the fi rst sense of normality and
abnormality, what may be normal for a
certain population may be simply dis-
tributed in some fashion that permits
measurements and averages. For exam-
ple, the ability to run is a standard
capacity for humanity. Running speed
across a large population can be sampled,
and an average running speed can be
calculated. Restoring an individual from
an impaired condition to a performance
condition in the activity of running
would aim at permitting this individual
to run at a speed approaching an aver-
age running speed (adjusted for other
variables, such as age and general
health). In contrast, a specialized enable-
ment for running could elevate an indi-
vidual’s near-average running speed
to a speed far in excess of that average.
A remarkable enablement like this
would place a modifi ed runner not just
among the fastest of humans but as a
runner who is far faster than any human
has been before. Running is a typical
human activity, but this specialized
enablement would therefore exceed
normal performance for this function.
The ability to run at speeds of 50 or 60
miles an hour is no mere enablement
or enhancement but is an extraordinary
augmentation.
Next, consider a specialized enable-
ment that modifi es arms into effective
wings, permitting fl ight. This is not
an enhancement of any normal human
functioning or activity. There is no typi-
cal or average performance level for
unassisted human fl ight. Humans can
fl y by attaching themselves to a fl ying
apparatus such as a hang glider or a jet
airplane, but we are talking about physi-
ological modifi cations to the body to
permit fl ight. A specialized enablement
like this isn’t any sort of enhancement to
a human ability. Although there is a kind
of mechanical continuity between get-
ting strapped tightly into a hang glider
and getting wings directly integrated
into one’s upper body, waving one’s
arms up and down is different from
moving one’s wing to fl y. Acquiring
the ability to fl y is not a simple enhance-
ment but a way to transcend standard
human capacities, through a radical
augmentation.
Locating the proper place for such
extraordinary and radical augmentations

Neuroethics Now
131
is not simply a matter of drawing a
straight line from therapies to enhance-
ments and on to truly amazing enhance-
ments. The point of truly radical
modifi cation is not about normality at
all; it aims not at being average, or
above average, but at being special or
nearly unique. Furthermore, acknowl-
edging the social context for fully
classifying types of modifi cations and
evaluating performance enhancement
remains just as important. In the sixfold
scheme that we present subsequently, a
neutral term is followed by both a nor-
mative term for the modifi cation and a
civic classifi cation for the modifi cation.
It is important to reiterate how many
sorts of emerging alterations could be a
treatment, supplement, or modifi cation
depending on the individual altered,
the purpose for the alteration, and the
standard against which functioning is
compared.
1 ) A treatment aims at relief from an
impairment, perhaps regeneration,
and possibly restoration of struc-
ture or function as well. If relief
and/or restoration are reliably
effective, a treatment is a therapy.
With supportive tools/training, a
therapy contributes to rehabilita-
tion. In the context of appropriate
social accommodation, rehabilita-
tion is also generic enablement.
2 ) A supplement to an individual’s
standard functioning aims at
exceeding population norms. If
that aim is reliably attained with-
out deleterious side effects, a
supplement is an enhancement.
An enhancement that dramatically
exceeds norms is an extraordinary
augmentation. In the context of
unusual performance expectations,
an extraordinary augmentation can
be a specialized enablement.
3 ) A modifi cation adds a nonstandard
capacity to an individual’s structure
and/or function in order to tran-
scend human capacities. If reliably
practical, a modifi cation provides
radical augmentation. In the context
of unusual performance expecta-
tions, a radical augmentation can
also be a specialized enablement.
Generic enablement, self-improvement,
and specialized enablement are highly
fi eld-sensitive classifi cations. Whether
someone remains enabled, in a generic
or specialized way, or enjoys self-
improvement always depends on a per-
son’s surrounding social conditions.
If supportive assistance and a welcom-
ing environment were absent or taken
away, enablement would be eroded,
and rehabilitation would suffer.
Enhancement will similarly be evalu-
ated within social contexts. In a social
atmosphere of bemused toleration, an
enhancement may be about cosmetic
vanity or lifestyle choice.
68
In contexts
of social approval, an enhancement may
amount to valuable capacity extensions
or at least acceptable self-improvements.
If social acceptance shifts to disap-
proval, however, enhancements might
be regarded as self-indulgence or self-
abuse. As for extraordinary or radical
augmentation, after a person ceases spe-
cial operations and returns to ordinary
life, that augmentation may be classi-
fi ed as an unfair advantage requiring
some countervailing disablement to
permit social participation. Alternatively,
such augmentation could be regarded as
a regrettable impairment (what we call
“postenablement distress syndrome”)
that necessitates rehabilitation, and
uncivil behavior may require psycho-
logical readjustment.
Societal judgment is hardly the same
as civic validity or social fairness. That’s
why enhancements and augmentations
should be separately evaluated accord-
ing to standards of civil order and secu-
rity and principles of equality and justice.

Neuroethics Now
132
What a society may value as a self-
improvement could actually be driven
by prejudices about desirable appear-
ances, gender and sexuality, ethnic and
minority status, ageism and ableism,
and so on. What is regarded as becom-
ing who one should be or attaining
enhancement may, in practicality, have
less to do with deviating from normal-
ity and more to do with approaching
conformity.
69
Social opinions on certain
augmentations may prove fi ckle, shift-
ing from “love it” to “hate it” as rapidly
as does the public appetite for fashion.
Historical context matters as well.
An enhancement, for the generation
that invents it and uses it, can become a
therapy for the next generation, if this
enhancement is later regarded as essen-
tial for conforming to normal health.
70
Societies constantly review and revise
what counts as normal human function-
ing. Interventions that delay the effects
of aging, for example, would be fi rst
applied as treatments for the elderly,
but the next generation may use them
to enjoy an unusually enhanced middle
age. A subsequent generation may accel-
erate the use of that intervention into an
extraordinary augmentation that can be
utilized when still young.
71
Over gen-
erations, the extraordinary can become
the familiar and expected. Modifi cations
that had once counted as radical aug-
mentations may recede to the status of
ordinary self-improvements.
Neuroethical Concerns about Self-
Augmentation
Perhaps no other anticipated augmen-
tation has been a greater subject of spec-
ulation than so-called enhancements
proposed to directly affect conscious-
ness, personality, agency, and the self.
A principled neuroethics, intent on
assigning moral priorities, must appre-
ciate the priority of maintaining a self
that is capable of morality. The pragmatic
framework that distinguishes rehabili-
tation, enhancement, and augmentation
from applications in enablement per-
mits a more nuanced analysis and prag-
matic disentanglement of the ethical
issues that arise in this most sensitive of
matters.
Examples of cognitive alterations,
whether accidental or deliberate, that
could lead toward self-discontinuities
or the creation of new self-identities
include memory emendation or erasure;
shifting of core interests and drives;
intensifying focus, determination, per-
severance, or self-preservation; modifi -
cations of affective processes involving
optimism, self-confi dence, attachment,
trust, suspicion, aggression, loyalty, or
bravery; enhancement of intellectual
abilities far beyond standard perfor-
mance; revision of core moral beliefs or
reversal of key moral attitudes; changed
weightings of moral considerations
relative to other concerns; alterations
to processes of social cognition; and
changes to ways that social norms and
duties are prioritized.
Some potent cognitive enhancers and
augmentations may modify self-identity.
Across a range of sensory, affective,
motor, social, and intellectual neurocog-
nitive functions there lies a potential
for dramatic alterations to the ways
that we experience and understand
ourselves. The sense of a unifi ed self
and self-awareness, to the extent that
any physiological sense can be given
to the self, appears to derive from, and
depend on, numerous contributions
from cross-communicating components
of the brain. Even modest alterations
to some critical neural processes can
have dramatic effects on personality
and temperament, or even identity and
authenticity.
72 , 73 , 74 , 75 , 76
Whether accom-
plished through pharmacological/
nanoscale agents, deep-brain or tran-
scranial stimulation, tissue and genetic
implantation/grafting, brain-to-brain

Neuroethics Now
133
interfacing, or computing implants/
prosthetics (and so on), effective altera-
tions can amount to radical self-
transformation.
77 , 78 , 79 , 80 , 81 , 82 , 83
Regardless of whether the sense of
self has a substantial, constructed, or
fi ctional basis, when contributory neu-
rological processes are altered, there
could be serious consequences for self-
identity. No abstract argument from neu-
roessentialism is needed to suggest the
genuine empirical possibility that dra-
matic alterations to brain and bodily
functions can change not just personal-
ity or temperament but the continuity
of the self that one recognizes oneself to
be.
84 , 85 , 86 , 87
Furthermore, if self-identity
becomes fl exible or even fungible, addi-
tional, deeper questions about authentic-
ity, autonomy, competence, responsibility,
and culpability arise.
88 , 89 , 90 , 91 , 92
Legal
implications fostered by any of these
possibilities will have far-reaching social
ramifi cations.
93 , 94 , 95
Neurocognitive alterations to one’s
personality or even self-identity can
generate particularly thorny issues and
questions. For instance, suppose there
were some neural modifi cation to brain
function that increases one’s capacity to
be courageous under anxiety-provoking
conditions. As a treatment for some-
thing such as extreme shyness, this
adjustment in courage could therapeu-
tically restore normal functioning, by
accommodating a society’s preference
for people enabled for some extrover-
sion or boldness. However, in other
societies unaccustomed to this forward-
ness and boldness, that same treatment
could cause a disabling personality
disorder. If administered to a person
desiring greater courage than normal,
the treatment would produce increased
confi dence, and a society may or may
not judge that as an enhancing self-
improvement. An extraordinary aug-
mentation could permit a person to
display maximal bravery despite fear
and stress. A radical augmentation could
even be envisioned, if the capacity to
feel either fear or courage was overrid-
den, producing a level or type of brav-
ery that transcends human standards.
What societies are able to judge about
those extreme augmentations will be
diffi cult to predict. It will, to a large
extent, depend on the specialized pur-
poses that such augmentations serve.
An illustrative case of a specialized
enablement is the military use of radi-
cal self-augmentation to improve sol-
dier performance in the fi eld.
96
The
perspectives of the soldier, the military,
and society must be taken into account
as ethical concerns are raised. Perhaps
we are on the verge of a revolution in
neural engineering that will allow tech-
nical modifi cation of the brain to improve
character and to enhance morality.
97 , 98 , 99
But here some skepticism—and even
cynicism—has its place. Categorizing
this matter as a question of moral
enhancement just because it concerns a
character trait associated with virtue
and morals must be inadequate, for
reasons outlined in previous sections
and elsewhere.
100
Once again we must
go beyond enhancement. Bravery aug-
mentation for a career soldier might
be regarded as consistent with self-
improvement, at least during active
service. If that specialized enablement
were applied to a civilian, the case would
be entirely different. When conditions
of extreme personal risk are needed to
make one feel challenged and fulfi lled,
life can’t be quite the same anymore. The
idea of an army of volunteers intending
to pursue a military career who receive
bravery augmentation raises some ethi-
cal concerns, but not as many concerns
as an army of drafted conscripts given
the same augmentation.
To provide another scenario, let us
suppose a neurocognitive alteration orig-
inally designed as a treatment to allevi-
ate guilt-related anxieties resulted in a

Neuroethics Now
134
person’s capacity to complacently kill
enemy combatants in warfare without
moral qualms or postbattle mental
trauma.
101
Is this a case of preventative
treatment or a form of moral enhance-
ment of a soldier’s character? Suppose
this modifi cation is done to a career sol-
dier, enhancing battlefi eld performance
so that she or he becomes the effective
soldier she or he has wanted to be. This
brain alteration could be classifi ed as a
self-improvement, if society approves
of soldiers being all they can be. Yet
this alteration is better classifi ed as a
specialized enablement, ensuring high
performance during and after frontline
operations. If a person’s empathy-free
and guilt-free capacity to kill becomes a
stable part of who she or he is, a differ-
ent self has become militarily enabled
by getting morally impaired. What really
counts as a character virtue is by no
means an assured matter, and the fi eld
of military ethics must attend to these
neuroethical concerns.
102
Irreversible brain alterations to mili-
tary conscripts that dramatically alter
self-identity to the point at which an
individual can only function as a soldier
are the sort of manufacture of a “single-
use human” that deserves the closest
ethical scrutiny. By contrast, reversible
brain modifi cations that only temporar-
ily enhance a career soldier’s capaci-
ties may be easier to ethically justify.
If the enhanced warfi ghter is inevitable,
a soldier specially enabled for battle
shouldn’t be psychologically damaged
in the process or predisposed only for
confl ict engagement.
103 , 104
Neither safe and effective alteration,
voluntary alteration, nor reversible alter-
ation can entirely ease concerns here.
What will count as safe and effective
when an alteration utilized as an enable-
ment under extraordinary circumstances
exerts an unpredictably unique infl u-
ence on one’s conception of oneself,
one’s self-worth, and one’s self-identity?
The performance expectations that soci-
ety places on professionals in general,
and rehabilitation expectations placed
on criminals, already distort the prac-
tical meaning of making a voluntary
choice. Would soldiers be allowed to
have the safe and effective choice to
decline augmentation?
105 , 106 , 107
Research
testing of mental stimulants, brain-
computer interfaces, and bionic pros-
thetics on military personnel
108 , 109 , 110 , 111
has already aroused cautionary ques-
tions and stances.
112 , 113 , 114 , 115
Reversibility may reduce ethical wor-
ries, but because self-identities can be
involved with extreme augmentations,
applying only temporary alterations
during specialized activities isn’t going
to be as reliably precautionary as one
may imagine. If someone appreciates
who he or she is while augmented far
more than who he or she used to be,
voluntary despecialization may be
diffi cult to obtain. From the perspective
of this person, loss of augmentation
may represent a destructive harm to
his or her own self and his or her
sense of who he or she essentially is.
De-enablement could be equivalent to
self-impairment or self-erasure, and this
is highly consequential to postenable-
ment distress.
Postenablement: Accommodation or
Inclusion?
When an enabled individual reenters
a civil society that is unready to accom-
modate extreme augmentation, we must
ask what society really owes this indi-
vidual. The option of detainment, de-
enablement, and rehabilitation can
appear to be the right course to take.
Perhaps this “deviant” new person
might be deemed too abnormal and
problematic for society. Alternatively,
a duty of inclusion could dictate greater
civic fl exibility and an obligation to
accommodate citizens regardless of

Neuroethics Now
135
“disability” (inclusive of postenable-
ment syndrome). Contemplate a soci-
ety simultaneously pursuing the generic
enablement of citizens trying to live
productive lives while denying that
same opportunity to those who have
honorably served specialized duties.
Ethics may not contort so far as to jus-
tify enabling some while de-enabling
others.
Supposing that the “real” person
prior to an augmentation is the genuine
citizen or derogating the augmentation
as an addiction or appendage won’t
stand up to scrutiny if and when the
augmentation is truly essential to the
person in question. Where persons are
involved, rights to self-determination
and autonomy suggest that a particular
right to mental self-determination should
apply.
116
The ideals of self-worth and
full inclusion place an even greater obli-
gation on society to ensure ample and
equal participation in pursuing a liveli-
hood and in enacting civic roles. The
sorts of dramatic changes to society
necessitated by full inclusion for many
radically augmented persons exceed the
imaginations of all but expert futurists
and science fi ction writers.
Societies would be wise to avoid a
forced choice between regretfully de-
enabling persons or struggling to accom-
modate radically augmented persons.
If special-use persons are created for par-
ticular fi elds, their specialized enable-
ment shouldn’t later become the cause
for their disablement in civil society.
The ethical duty to ensure performance
capabilities and social enablement cov-
ers each and every person, no matter
the manner of their creation. Prevention
avoids that forced choice, however.
Modifi cations that do not create new
identities, or rapidly reversible modifi -
cations that only transiently affect
identity, should be preferred. If an inte-
grated augmentation did alter personal
identity, gradually diminishing that
augmentation—with every effort to
gently guide (yet another) personal
transformation toward a stable and
confi dent personal identity—would be
preferable to abrupt cessation without
follow-up care.
Decommissioning an augmentation
won’t be as easy as these proposals may
make it sound. Nevertheless, although
augmentation removal may leave an
individual bewildered, it needn’t leave
him or her degraded. The same duty to
ensure capacities for enablement still
applies here—proper rehabilitation and
accommodation should provide for this
person’s generic enablement. Devaluing
the person as if that person shouldn’t
have existed is neither necessary nor
warranted. After all, service with a spe-
cialized enablement was sought, and at
one point, that augmented person was
very much valued. The removal of a
specialized enablement doesn’t make
that person any less special. This option,
by contrast, demands the full dignity
and equality of all persons by deliver-
ing generic enablement no matter the
course of that person’s life. There can
be no repeat of the utilitarian argument
favoring the prevention of “disabled”
people by devaluing those living with
an impairment.
Neuroethics Enabled with
Augmented Principles
In summary, we have applied an inte-
grated and pragmatic standpoint to
sketch a schema for discerning the nature
of therapy, enhancement, and/or enable-
ment. This scheme, as our discussion of
a handful of potential cases and con-
cerns can illustrate, enables neuroethics
to better perceive and address coming
opportunities and concerns. Toward this
end, we conclude with a brief enlarge-
ment of the four ethical principles of
neuroethics mentioned in the fi rst sec-
tion in light of the analyses offered in

Neuroethics Now
136
later sections. Elsewhere we defend this
pragmatic principlism as the creation of
fl exible yet fi rm guidelines for evaluat-
ing emerging issues before they become
overwhelming or intractable.
117
Here we
point to the way that this neuroethics
beyond normal can fulfi ll a primary
responsibility of any ethics: to maintain
focus on the centers of moral worth,
so that moral persons can fl ourish and
promote morality in their societies. The
principles of autonomy, nonmalefi cence,
benefi cence, and justice nobly serve this
responsibility, and our ethical responsi-
bilities are only growing as novel bio-
and neurotechnologies are expanding
human horizons. Augmentation is clearly
in order.
Augmenting autonomy yields self-
creativity . The right of persons to auton-
omously direct their lives should be
extended to the right to re-create them-
selves to enrich their lives. Access to
self-creative modifi cations, even to the
point of making new selves, should be
protected, so long as other principles are
respected along the way. Self-creativity
must not be confl ated with individuality
or peculiarity; people should also be
allowed to re-create themselves to more
closely conform to desired group stan-
dards (so long as those standards do not
themselves involve loss of autonomy or
violations of the other three principles).
A modifi cation is unethical if it contracts
creativity—for example, by reducing
responsible autonomy or the capacity
for further creativity, reducing basic
capabilities to support one’s self, or lim-
iting potential competencies to improve
one’s standard of living and well-being.
Augmenting nonmalefi cence yields
nonobsolescence . The duty to avoid unrea-
sonably harming people should be
extended to avoid the creation of obso-
lete people, especially single-use people
that are so irreversibly specialized by
radical body/brain modifi cations that
career and lifestyle options become too
limited. A modifi cation is unethical if it
unreasonably risks producing a per-
son with peculiar or radical enhance-
ments that excessively restrict future
self-creativity, or if it reduces empower-
ment or citizenship.
Augmenting benefi cence yields
empowerment . The duty to advance the
welfare of others should be extended to
the duty to increase the capabilities of
people to autonomously live indepen-
dent and fulfi lling lives. A modifi cation
would be considered to be unethical if it
causes unreasonable harms to a person,
makes a person more dependent on
others (especially to the point of losing
effective citizenship, the fourth principle),
or reduces a person’s capacity to pursue
his or her own well-being.
Augmenting justice yields citizenship .
The duty to fairly distribute scarce goods
should be extended to the duty to guar-
antee everyone’s ability to be a free,
equal, law-abiding, and participatory
citizen. A modifi cation would be uneth-
ical if it risks debilitating a person’s
capacity for fulfi lling the roles and
responsibilities of engaged civic life
or enjoying the rights and obligations
of citizenship.
An unprincipled ethics, forgetting
how to sustain the vitality of morality,
only contradicts and destroys itself.
Persons are enduring ends no matter
how much they may also come to view
their selves as transformable means.
From the soundest medical treatment to
the most radical augmentation, we may
hope for enhancements and enable-
ments, but we’d better ensure futures
that we all can live in, and in which we
can live well together. It is our hope
that neuroethics—perhaps of the type
proposed here—will be useful to these
pursuits.
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