Inbox: Clarke, S. and Roache, R. 2012: ‘Introducing transformative technologies into democratic societies’, Philosophy & Technology 25/1: 27-45. Bostrom, N. and Roache, R. 2007: ‘Ethical issues in human enhancement’, in J. Ryberg, T. Petersen, and C. Wolf (eds.) New Waves in Applied Ethics (Basingstoke: Palgrave Macmillan): 120-52. BIOCONSERVATISM , BIOLIBERALISM , AND REPUGNANCE Roache, R. 2017: 'What sort of death matters?' Journal of Medical Ethics ​43/11: 727-28. Roache, R. 2017: 'Is it better to die than to be lonely?' Journal of Medical Ethics​ 43/9: 575-76. Roache, R. and Clarke, S. 2009: ‘Bioconservatism, bioliberalism, and repugnance’, Monash Bioethics Review 28 (March): 04.1-04.21. Roache, R. 2008: ‘Ethics, speculation, and values’, Nanoethics 2: 317-27. ## Smart policy: Cognitive enhancement and the public interest Bostrom, N. and Roache, R. 2011: ‘Smart policy’, in J. Savulescu, R. ter Muelen, and G. Kahane (eds.), Enhancing Human Capacities (Oxford: Wiley-Blackwell). *Highlight [page 10]:* the composition of infant formulas and maternal nutrition can have a significant life-long impact on cognition. Recent studies have indicated that children’s IQ can be improved by increasing maternal docosahexaenoic acid (DHA) intake during pregnancy23, by supplementing infant formula with DHA24, and by increasing the period for which the infant is breastfed25. Good infant nutrition can increase a child’s IQ by as much as 5.2 points in cases where low birth weight infants are fed human milk26. *Highlight [page 10]:* it should be a priority to conduct more research to establish the optimal composition of infant formula in order to maximize cognitive ability in bottle-fed children. Regulation could then be put in place to ensure that commercially available formula contains these nutrients. Public health information campaigns could further promote the use of enriched formula or breast-feeding practices. *Highlight [page 10]:* Iodine deficiency adversely affects health in a number of ways, and its specific effect on cognition is severe: iodine deficient populations average between 12.5 and 13.5 IQ points less than normal populations29. The deficiency can be easily treated by supplementing food with iodized salt; an intervention costing about $0.05 per person per year30. *Highlight [page 11]:* Given the scale and adverse effects of iodine deficiency compared with the relative ease of treating it, this final example powerfully illustrates that cognitive enhancement policy need not centre on preparing the ground for sophisticated, yet-to-be-realized technologies. ‘Smart policy’ should, rather, take as its starting point the recognition that effective cognition is not only subjectively valuable to individuals, but also delivers significant social, cultural, financial, and scientific benefits. Maximizing these benefits need not be difficult, risky, controversial, or expensive. *Highlight [page 11]:* Conceptualize biomedical cognitive enhancers as part of a wider spectrum of ways of enhancing the cognitive performance of groups and individuals. Modify the disease-focused regulatory framework for drug approval into a wellbeing-focused framework in order to facilitate the development and use of pharmaceutical cognitive enhancement of healthy adult individuals. Assess risks by balancing against benefits rather than against the status quo, and by allowing individuals to determine risk acceptability where appropriate. Provide public funding for academic research into the safety and efficacy of cognitive enhancers, for the development of improved enhancers, and for epidemiological studies of the broader effects of long-term use. Increase public funding for research aimed at determining optimal nutrition for pregnant women and newborns to promote brain development. Address the problem of iodine deficiency as a global priority. ## Enhancing Conservatism Roache, R. and Savulescu, J. 2016: 'Enhancing conservatism', in Clarke, S. and Guibilini, A. (eds.) The Ethics of Human Enhancement: Understanding the Debate (Oxford: OUP): 145-159. *Highlight [page 3]:* Transhumanists typically welcome developments that aim to overcome human biological limitations, such as our expected lifespan and ordinary levels of intelligence, as some novel biotechnologies promise to do. Bioliberals do not necessarily view such technologies as good but they tend to reject most of the prominent bioconservative reasons for opposing them. For bioliberals, as for political liberals, good reasons to ban novel technologies must make reference to their harmfulness, or the inherent unfairness of their uses. Bioliberals are, as a result, accepting of new technologies on the condition that they are sufficiently safe, fairly distributed, and so on. Bioconservatives oppose the use of these technologies. While some of their reasons for concern—such as those relating to safety, fairness, and distributive justice—are acknowledged by transhumanists and bioliberals, their main objections are rarely given much weight by their opponents. *Highlight [page 3]:* Bioconservatives are often political conservatives, and their arguments reflect mainstream conservative thought, including a greater reliance on appeals to intuition than is typical of liberals. *Highlight [page 3]:* Bioconservatives oppose enhancement because they believe the goods that enhancement promises to be less valuable than the goods it would destroy *Highlight [page 4]:* an intervention that promotes bioconservative values by a means that bioconservatives oppose *Highlight [page 4]:* Leon Kass and Michael Sandel—perhaps the two most prominent bioconservatives, *Highlight [page 4]:* worry that technology develops so fast that we risk embracing it before considering whether what it offers is valuable *Highlight [page 4]:* w]hen science moves faster than moral understanding, as it does today, men and women struggle to articulate their unease. […] The genomic revolution has induced a kind of moral vertigo’ (Sandel 2004, p. 1). *Highlight [page 4]:* For Kass, this greater value ‘may have something to do with what is natural, or what is humanly dignified, or with the attitude that is properly respectful of what is naturally and dignifiedly human’ *Highlight [page 4]:* For Sandel, enhancement ‘represent[s] a kind of hyperagency—a Promethean aspiration to remake nature, including human nature, to serve our purposes and satisfy our desires’; an attitude that ‘misses and may even destroy […] an appreciation of the gifted character of human powers and achievements’ (Sandel 2004, p. 5). *Underline [page 5]:* an attitude that ‘misses and may even destroy […] an appreciation of the gifted character of human powers and achievements’ *Highlight [page 5]:* the bioconservative objection that we should avoid enhancement because it might destroy more value than it creates is unconvincing unless bioconservatives have good reason to believe that important values are more effectively promoted by abstaining from enhancement than by pursuing it. Indeed, some bioliberals have argued that some bioconservative values are better promoted by enhancement than by opposition to it.4 *Highlight [page 5]:* The caution advocated by Kass and Sandel reflects a typically conservative view that the way things are (or, perhaps, the way things used to be in some bygone era when everything was better) is not the result of current whims or random circumstances; rather, the current arrangements—and in particular the traditions that conservatives esteem5—have been shaped by the accumulated wisdom of our ancestors. Let us call this accumulated wisdom of our ancestors established wisdom. Reverence for established wisdom, combined with pessimism about the ability of society to withstand radical change, 6leads conservatives to oppose attempts to overturn the status quo. Bioconservatives can argue, then, that by resisting enhancement we concur with established wisdom. Since established wisdom plausibly exceeds that of bioliberals, it is more likely that bioconservative values will be preserved by resisting enhancement than by enhancing. *Underline [page 5]:* Reverence for established wisdom, combined with pessimism about the ability of society to withstand radical change, 6leads conservatives to oppose attempts to overturn the status quo. *Highlight [page 6]:* Kass and Sandel, like Burke, exhibit ‘reverence to antiquity’. Kass bemoans the fact that, ‘[t]oday, one must even apologise for voicing opinions that twenty-five years ago were nearly universally regarded as the core of our culture’s wisdom on these matters’ *Highlight [page 6]:* questions largely lost from view—questions about the moral status of nature, and about the proper stance of human beings toward the given world’—questions from which ‘modern philosophers and political theorists tend to shrink’ (2004, p. 2). *Highlight [page 6]:* Often, such revolutions have been insufficiently situated in the realities of human psychology and capacity for social life. *Highlight [page 6]:* Kass in particular seems to object even to gradual social change, as the remarks quoted above suggest. We might take him not only to view radical change as undesirable, but to endorse the stronger view that the status quo represents the ideal state, from which even gradual changes are undesirable. This makes him vulnerable to a charge of status quo bias.8 *Highlight [page 7]:* Even conceding that established wisdom likely outweighs that of today’s thinkers, an appeal to established wisdom is insufficient to show that what bioconservatives value is better safeguarded by opposing enhancement than by permitting it. Clearly things do change and progress is made; history is replete with attempts to improve the human condition, and indeed the human. It is far from clear that the desire to enhance is opposed to established wisdom, rather than reflective of it. The desire to enhance traits such as intelligence, strength, and self-confidence arises from a culture whose established wisdom values these traits. *Highlight [page 8]:* While appeal to intuition plays a central role in moral evaluation and reasoning, it plays a dominant role in conservative moral reasoning, since conservatives often resist attempts rationally to analyse and evaluate their moral intuitions. 13A characteristic conservative appeal to intuition enables bioconservatives to insist both that enhancement conflicts with established wisdom and that it is not possible to articulate exactly how and why this is the case. *Highlight [page 8]:* bioliberals do not share bioconservatives’ intuition that enhancement is bad—meaning that in order to decide who has the right intuitions, we must appeal to some standard of evaluation that is independent of individuals’ intuitions. *Highlight [page 8]:* That they are likely to become more intuitively accepting of it even if it is in fact morally objectionable points to the conclusion that, again, its moral acceptability must be assessed with reference to considerations independent of individuals’ unanalysed intuitions. *Highlight [page 8]:* Following Fukuyama, let us use the term ‘factor X’ to denote that difficult-to-define aspect of humanity that bioconservatives worry will be undermined by enhancement. *Highlight [page 9]:* Sandel notes when he comments that ‘[w]hen science moves faster than moral understanding, as it does today, men and women struggle to articulate their unease’ (Sandel 2004, p. 1), and as Kass acknowledges in his remark that ‘[i]t is difficult to put this disquiet [about enhancement] into words. We are in an area where initial repugnances are hard to translate into sound moral arguments’ (Kass 2003, p. 17).17 *Highlight [page 11]:* To a society armed with biotechnology, the activities of human life may come to be seen in purely technical terms, and more amenable to improvement than they really are. (Kass 2008, pp. 302–3) *Highlight [page 12]:* what is at issue is not whether enhancement would promote worthwhile values but how it might change public perception of the enhanced and/or the unenhanced. If it would lead people, for example, to focus abstractly on human capacities and their usefulness (or otherwise), and to take an impersonal view of other people as things capable of being improved rather than as individuals, then enhancement could lead to dehumanization. *Highlight [page 12]:* They may instead maintain that while current levels of factor X in society are too low, there exists an ideal level which it would be undesirable to exceed *Highlight [page 12]:* This is the problem of overshoot. *Highlight [page 13]:* There is only too great a tendency in the best beliefs and practices to degenerate into the mechanical; and unless there were a succession of persons whose ever-recurring originality prevents the grounds of those beliefs and practices from becoming merely traditional, such dead matter would not resist the smallest shock from anything really alive, and there would be no reason why civilization should not die out, as in the Byzantine Empire. Persons of genius, it is true, are, and are always likely to be, a small minority; but in order to have them, it is necessary to preserve the soil in which they grow. Genius can only breathe freely in an atmosphere of freedom. Persons of genius are, ex vi termini, more individual than any other people—less capable, consequently, of fitting themselves, without hurtful compression, into any of the small number of moulds which society provides in order to save its members the trouble of forming their own character. (Mill 1860/1909) *Highlight [page 13]:* We are right to worry that the self-selected non-therapeutic uses of the new powers, especially where they become widespread, will be put in the service of the most common human desires, moving us toward still greater homogenization of human society—perhaps raising the floor but greatly lowering the ceiling of human possibility, and reducing the likelihood of genuine *Highlight [page 14]:* freedom, individuality, and greatness. […] Indeed, such homogenization may be the most important society-wide concern, if we consider the aggregated effects of the likely individual choices for biotechnical ‘self-improvement,’ each of which might be defended or at least not objected to on a case-by-case basis. (Kass 2003, p. 16)21 *Highlight [page 15]:* Bioconservatives are surely right that we ought to take serious account of established wisdom and proceed with caution. But we ought not to be paralysed by fear and stuck in the past. Change, including enhancement, can be for the better, in any plausible account of value. ## Transformative tech democratic societies We can contrast moral intuitions with explicit moral judgments reached as a result of reasoned evaluation. In the case of the latter, but not always in the case of the former, one is able to support one’s moral judgment with reasons. Intuitions, which are generally accompanied by emotions, play a key part in conservative accounts of moral reasoning. ## Choosing children Jonathan Glover book review *Highlight [page 1]:* Jonathan Glover’s 2004 Uehiro Lectures *Highlight [page 1]:* Glover asks what disability is; answer: a limitation of normal functioning which impairs the capacity for human flourishing. *Highlight [page 1]:* Glover concludes that conditions like deafness and blindness are obstacles to flourishing, and that any desire disabled people have to embrace their disability is due to such factors as valued compensations, ‘sour grapes’, and lack of knowledge about what a disability-free life would be like. *Highlight [page 1]:* Glover needs to demonstrate why an ability to see or hear is more fundamental to flourishing than other abilities that may be important to the flourishing of some people but not others, such as an ability to play a musical instrument. *Highlight [page 2]:* two ‘dimensions’ of ethics: making the world a better place, and what we owe to people. *Underline [page 2]:* two ‘dimensions’ of ethics: making the world a better place, and what we owe to people. *Highlight [page 2]:* If parents choose an embryo with a deafness gene over a genetically healthy embryo, for example, the resulting child is not harmed by the choice. If the choice is bad, this must be because it makes the world a worse place than it would have been had the other embryo been chosen. However, this explanation is insufficient. Many of our choices make the world a worse place than it would have been had we chosen differentlysuch as the choice to spend money on a holiday instead of donating it to charity—but not all such choices are immoral. *Highlight [page 2]:* he claims that if parents can remove an obstacle to their children’s flourishing without unreasonably burdening themselves, they owe it to their children to do so. *Highlight [page 3]:* Restrictions may be needed to prevent social evils like “a genetically based caste system” (p. 78), in which the rich ensure the superior genetic quality of their descendents; but Glover is pessimistic about the effectiveness of such measures, citing the limited success of existing attempts to “regulate the market in the interest of wider values” (p. 80). Such pessimism may be unwarranted: whilst, for example, global restrictions on carbon emissions have been difficult to enforce, international cooperation to tackle terrorism has been more successful, and so it may be difficult to determine antecedently whether governments will cooperate to regulate genetic choice. *Highlight [page 3]:* First, some qualities that parents choose for their children may not benefit society: these are ‘positional goods’ whose value to those who have them depends on others not having them. Second, in considering which human qualities to preserve, the relevant question is not ‘Are they part of human nature?’ but ‘Are they valuable?’, so human nature is something of a red herring. *Underline [page 3]:* positional goods’ whose value to those who have them depends on others not having them *Underline [page 3]:* the relevant question is not ‘Are they part of human nature?’ but ‘Are they valuable?’, so human nature is something of a red herring *Highlight [page 3]:* Glover is optimistic about the existence of certain shared values, which he sees as accounting for some cross-cultural points of consensus about what constitutes good and bad lives. *Highlight [page 3]:* any change must take place gradually, and guided by our existing values—and as our values change, so might the genetic choices we make. ## After Prozac Liao, S.M. and Roache, R. 2011: ‘After Prozac’, in J. Savulescu, R. ter Muelen, and G. Kahane (eds.), Enhancing Human Capacities (Oxford: Wiley-Blackwell). *Highlight [page 2]:* For example, instead of feeling spontaneous love for their newborn child, it is common for mothers—perhaps owing to postpartum depression—to feel instead estrangement and resentment. *Highlight [page 2]:* Indeed, in being able to induce parental love that one does not feel spontaneously, one may also be able at least to partially fulfill a duty to love a child. *Underline [page 2]:* induce parental love that one does not feel spontaneously *Highlight [page 3]:* The enormous market in self-help books alone should give us pause before discounting the potential benefits of mood enhancement: an enormous number of mentally healthy people want to improve their mood, and are willing to pay generously in order to do it. *Highlight [page 4]:* Except perhaps in cases of people whose guilt may be deemed pathological11, altering mood such that our experience of guilt is subdued or diminished may turn out to be disastrous, since it may result in an increase in immoral behaviour, which is likely to be harmful to others. As examples of an unintended side-effect, someone who believes that he is too shy and unassertive, and who wishes to use mood enhancement drugs to change this, might fail to strike the right balance and render himself over-aggressive rather than merely assertive. *Highlight [page 4]:* matters are more complicated when we consider the possibility of drugs whose effects are harmless to others when used responsibly nevertheless induce potentially harmful effects when used recklessly. In such a case, we might adopt similar policies to those governing alcohol use. In other words, we might restrict its use by those deemed incompetent, and respond to other cases of irresponsible use by punishing the resulting antisocial behaviour rather than further restricting the drug‟s use. The latter would introduce an incentive to use mood enhancement drugs in ways that are not harmful to others, and could be combined with educational campaigns designed to inform people about how to enhance responsibly. *Highlight [page 5]:* This demonstrates that a society that embraces mood-altering drugs ought not to content itself with addressing concerns about harm to others and equality. We are uneasy about drugs like soma because of their effects on those who use them: users end up living lives that are in some sense impoverished. *Underline [page 5]:* We are uneasy about drugs like soma because of their effects on those who use them: users end up living lives that are in some sense impoverished. *Highlight [page 6]:* According to Frankfurt, for one to be morally responsible for an action, the desire behind it must be one with which one identifies. For Frankfurt, this means that desire must be endorsed by a higher-order desire: we must desire to act upon that desire. *Underline [page 6]:* what matters in life is not simply enjoying pleasant experiences. We also want our experiences to bear the right sort of relation to reality *Highlight [page 6]:* what matters in life is not simply enjoying pleasant experiences. We also want our experiences to bear the right sort of relation to reality. We want to engage with the world, and we care whether things are going well or badly for us. As a result, we want to be able to recognise when life is going well or badly, and to respond accordingly. This points to the importance of maintaining what we might call a healthy outlook on one‟s life and the world. Many drugs can induce delusions in users, especially when used recklessly; for example, cannabis can induce psychotic episodes19. *Highlight [page 8]:* The acute-chronic model is instructive in thinking about emotional and mood states. While some unpleasant states like anxiety and depression may be appropriate and valuable in some cases, they can be disruptive and disabling if they continue indefinitely and bear no relation to the state of the subject or the world around her. There may be a case for enduring some of the former, „acute‟, types of state; but the latter, „chronic‟, types of state serve no useful function and are better alleviated. *Highlight [page 8]:* there is evidence to suggest that mentally healthy individuals hold a variety of overly positive illusions about themselves, and that their mental health is tied to their holding such illusions; whereas mentally unhealthy people perceive themselves, the world, and their future more accurately23. This research has been disputed24, but if there is any truth in the claim that illusions about oneself and the world promote can mental health, there are implications for our assessment of mood enhancement drugs. Specifically, focusing too heavily on the desirability of developing self-knowledge may be counter-productive for our attempts to enhance mood. We may ultimately be forced to choose between two highly valuable mental capacities: happiness and accurately perceiving reality25. *Highlight [page 8]:* Taylor, S. E. and J. D. Brown (1988) „Illusion and Well-Being: A Social-Psychological Perspective on *Highlight [page 8]:* Mental Health‟, Psychological Bulletin, 103, pp. 193-210 ## Human Engineering & Climate Change *Highlight [2]:* we consider a new kind of solution to climate change, what we call human engineering, which involves biomedical modifications of humans so that they can mitigate and/or adapt to climate change. We argue that human engineering is potentially less risky than geoengineering and that it could help behavioural and market solutions succeed in mitigating climate change. *Highlight [2]:* human engineering deserves further consideration in the debate about climate change *Highlight [5]:* Pharmacological meat intolerance *Highlight [7]:* Making humans smaller *Highlight [9]:* Lowering birth-rates through cognitive enhancement *Highlight [10]:* in the US, women with low cognitive ability are more likely to have children before age 18 (Shearer et al. 2002). So, another possible human engineering solution is to use cognition enhancements to achieve lower birth rates. Like education, there are many other, more compelling reasons to improve cognition, but the fertility effect may be desirable as a means of tackling climate change. *Highlight [10]:* Pharmacological enhancement of altruism and empathy *Highlight [11]:* While altruism and empathy have large cultural components, there is evidence that they also have biological underpinnings. This suggests that modifying them by human engineering could be promising. Indeed, test subjects given the prosocial hormone oxytocin were more willing to share money with strangers (Paul J. Zak et al. 2007) and to behave in a more trustworthy way (P. J. Zak et al. 2005). Also, a noradrenaline reuptake inhibitor increased social engagement and cooperation with a reduction in self-focus during a mixed motive game (Tse and Bond 2002). Similar effects have been observed with SSRIs in humans and animal experiments (Knutson et al. 1998). *Highlight [12]:* a number of experts on climate change seem to take far riskier solutions such as geoengineering seriously (House of Commons Science and Technology Committee 2010). If behavioural and market solutions were by themselves sufficient to mitigate climate change, it would not be necessary to take geoengineering seriously. Suppose that we should take geoengineering seriously and that behaviour and market solutions are by themselves inadequate to mitigate climate change. There are at least two reasons to take human engineering seriously. First, human engineering is potentially less risky than geoengineering. Second, human engineering could make behaviour and market solutions more likely to succeed. *Highlight [16]:* Our response is that acknowledge these risks exist, but also to point out that these risks should be balanced against the risks associated with taking inadequate action to combat climate change. If behavioural and market solutions alone are not sufficient to mitigate the effects of climate change, then even if human engineering were riskier than these other solutions, we might still need to consider it. Also, it is important not to exaggerate the risks involved in human engineering. This is a very real possibility, since people are generally less tolerant of risks arising from novel, unfamiliar technologies than they are of risks arising from familiar sources (Slovic 1987; Starr 1969). To counter this effect, it is worth remembering that some of the technology involved in human engineering – such as PGD and oxytocin – is already safely available for other uses, and that in non-climate change contexts, our society has been willing to make biomedical interventions on a population-wide scale. For example, fluoride is deliberately added to water with the aim of fortifying us against tooth decay, even though doing so is not without risks. Similarly, people are routinely vaccinated to prevent themselves and those around them from acquiring infectious diseases, even though vaccinations can sometimes even lead to death. Given that biomedical modifications are accepted in these other contexts, and given that climate change is at least as serious as these other problems, again it seems that we should consider human engineering. *Highlight [17]:* it seems that we should judge human engineering solutions on a case by case basis, and not rule all of them out tout court. *Highlight [17]:* Michael Sandel has argued that a problem with human enhancement is that it represents ‘a Promethean aspiration to remake nature, including human nature, to serve our purposes and satisfy our desires’ (Sandel 2004). *Highlight [19]:* There is evidence that many parents are indeed happy to give their children cognitive enhancements. For example, a great many parents – perhaps even too many 3are willing to give Ritalin to their healthy children so that they can concentrate and perform better at school, even though Ritalin is intended for children with ADHD and certainly has side effects.4 *Highlight [22]:* History is replete with examples of issues or ideas which, whilst widely supported or even invaluable now, were ridiculed and dismissed when they were first proposed. In 1872, Pierre Pachet, a professor of physiology at Toulouse, dismissed Pasteur’s theory of germs as a ‘ridiculous fiction’. An internal memo at Western Union in 1876 remarked that ‘this “telephone” has too many shortcomings to be seriously considered as a means of communication. The device is inherently of no value to us’. Lord Kelvin, the president of the Royal Society, claimed in 1895 that ‘heavier than air flying machines are impossible’. 5In 1943, Thomas Watson, the chairman of IBM, doubted that the world could need any more than five computers. And only a few decades ago, those who worried about climate change – now widely recognised as one of the most pressing problems of our age – were frequently dismissed as ‘tree-huggers’. The lesson here is that, whilst we may often be good at judging which ideas are unworthy of pursuing, we are nevertheless sometimes vulnerable to dismissing useful and valuable ideas. *Highlight [25]:* As we mentioned earlier, one way to reduce size and therefore carbon footprints is to reduce height. But another way to reduce size is to reduce weight, which would presumably be less controversial *Highlight [26]:* improved cognition and the health benefits of vegetarianism are goods in themselves. ## Making consequentialism more appealing *Highlight [page 1]:* Trolley problems’, an increasingly elaborate mainstay of moral philosophy since Philippa Foot Dirst described them in the 1960s, are designed to weigh consequentialist moral intuitions against conflicting deontological ones. *Highlight [page 1]:* Some argue that moral judgment is made on the basis of emotion alone, with reason providing merely post-hoc rationalisations of decisions already made.2 Emotion, these researchers hold, leads us to make deontological moral judgments, whilst reason leads us to make consequentialist ones *Highlight [page 1]:* correlation between a tendency towards consequentialist moral judgments and antisocial personality traits, including psychopathy.3 Psychopathy, of course, is characterised by stunted emotional response. *Highlight [page 3]:* In this case, it seems a no-brainer: of course Japan should implement tsunami tendenko, given that it is vastly superior to other evacuation strategies as a means to maximise survival. The problem is how to get Japanese citizens to buy into it without requiring them to be consequentialist psychopaths of the sort discussed by Bartels and Pizarro. *Underline [page 3]:* The problem is how to get Japanese citizens to buy into it without requiring them to be consequentialist psychopaths *Highlight [page 3]:* Koda frames tsunami tendenko in a way that emphasises self-preservation over helping others. He characterises it as, ‘run for your life to the top of the hill and never mind others or even your family when the tsunami comes’ [insert page ref]. This way of presenting the strategy makes salient that tsunami tendenko involves prioritising one’s own interests over those of others. As such, it is easy to see why some see it as unacceptably, and unrealistically, selDish. However, it could alternatively be characterised as, ‘run for your life to the top of the hill to ensure that others are not tempted to endanger themselves by waiting for you’. This more positive presentation makes salient that practising tsunami tendenko can be motivated by a desire to promote the survival of others as well as oneself, and that taking care of oneself can be a way of fulDilling one’s duties to others *Highlight [page 5]:* Bartels, D. M. and Pizarro, D. A. (2011): ‘The mismeasure of morals: Antisocial personality traits predict utilitarian responses to moral dilemmas’, Cognition 121/1: 154–61 *Highlight [page 5]:* Haidt, J. (2001): ‘The emotional dog and its rational tail: A social intuitionist approach to moral judgment’, Psychological Review 108/4: 814–34 ## Psychological Disadvantage and a Welfarist Approach to Psychiatry *Highlight [page 1]:* DSM-5’s problems are its over-emphasis on biological causes of mental distress and its classification of arguably normal states as disorders. *Highlight [page 1]:* the purpose of psychiatry—and of medicine generally—must be reconsidered if advances in medicine are to be effective in benefiting people. *Highlight [page 1]:* We advance an alternative framework in which medicine focuses not on disease but on psychological traits that, combined with other factors, reduce well-being. This ‘welfarist’ approach could avoid many problems encountered on the current model, bring order to those aspects of current medical practice that do not focus on curing disease, and target undesirable states regardless of whether they are symptomatic of disease. We call such states ‘psychological disadvantage’. *Underline [page 1]:* alternative framework in which medicine focuses not on disease but on psychological traits that, combined with other factors, reduce well-being. This ‘welfarist’ approach *Underline [page 1]:* disease. We call such states ‘psychological disadvantage’. *Highlight [page 2]:* This rise in mental illness is due to at least three factors: increased willingness to diagnose mental disorders, relaxation of diagnostic criteria, and invention of new mental disorders. Increasingly, psychiatry is expanding to include conditions that, whilst undesirable, are not intuitively symptomatic of mental disorder. For example, DSM-5includes the following conditions: fear of speaking in front of an audience (social anxiety disorder), depressive symptoms experienced two weeks after the death of a loved one (major depressive disorder), irritability and episodes of extreme behavioural dyscontrol in children (disruptive mood dysregulation disorder), a difficult-to-resist urge to bite the nails (bodyfocused repetitive behavior disorder), and smoking tobacco when one both craves to do so and persistently desires not to do so (tobacco use disorder) (APA 2013a, APA 2013b). *Highlight [page 3]:* Pathologisation is motivated by the assumption that, in order to be medically improved, a condition must be symptomatic of disease *Underline [page 3]:* Pathologisation is motivated by the assumption that, in order to be medically improved, a condition must be symptomatic of disease. *Highlight [page 4]:* BPS’s Division of Clinical Psychology argued that DSM-5’s ‘disease model’ of ‘distress and behaviour’ over-emphasises biological factors at the expense of social and psychological factors (BPS 2013: 23). BPS views this approach as having the following drawbacks: it encourages the view that psychiatric diagnosis is ‘an objective statement of fact’ rather than ‘a clinical judgement … subject to variation and bias’ *Underline [page 4]:* it encourages the view that psychiatric diagnosis is ‘an objective statement of fact’ rather than ‘a clinical judgement … subject to variation and bias’ *Highlight [page 4]:* Psychiatric diagnosis was used to control political dissidents in the Soviet Union, Romania and China, and elsewhere (van Voren 2010). In 1940s and 1950s Canada, thousands of orphans were misdiagnosed as mentally ill and transferred from orphanages to psychiatric hospitals, which received more generous federal funding. *Highlight [page 4]:* homosexuality was classed as a disorder by the APA until 1973, when it was omitted from DSM-II. *Highlight [page 5]:* many homosexuals underwent humiliating and traumatic ‘conversion therapies’. *Highlight [page 5]:* pathologising normality perpetuates a harmful belief in the significance of the difference between disease and normality. *Highlight [page 5]:* Whereas there is a clear diagnostic pathological difference between the brain scan and tissue biopsy of a person with a brain tumour or multiple sclerosis and that of a normal person, there is no such clear pathological difference between the brain of a normal person and the brain of someone with even a ‘hard’ psychiatric disorder such as schizophrenia. *Highlight [page 5]:* psychiatric disorders invite coercive treatment. The extreme is involuntary treatment but there are strong reasons to persuade people with disorders of the mind to accept therapy just because their mind is affected, *Underline [page 5]:* psychiatric disorders invite coercive treatment *Highlight [page 6]:* including their rationality. Both of these factors open the door to excessive intervention into the minds of people without real pathology. *Highlight [page 6]:* Historically, the purpose of medicine has been to treat and prevent disease, where diseases are conditions defined by clear pathologies: the presence of a malignant tumour, or a virus, for example. The basic ethical principle governing the practice of medicine is that treatment is offered in the best interests of the patient, who must consent to treatment before it begins. *Underline [page 6]:* Historically, the purpose of medicine has been to treat and prevent disease, *Highlight [page 6]:* identifying disadvantageous traits that are amenable to medical interventions, yet which should not be considered (in the absence of further pathological information) as diseases. We will call this new class psychological disadvantage. ## In Defence of Drinking Alone *Highlight [page 3]:* Olympic medalists who fail drugs tests are stripped of their medals. We might view drinking in social settings as a form of social enhancement: Ernest Hemmingway once said, ‘I drink to make other people more interesting’, and many of us have deepened a friendship with someone over a beer. Yet people do not view friendships cemented with alcohol as less valuable than those that develop solely in sober settings. Another example: the idea of enhancing our romantic attachments through the use of drugs has been met with alarm by some people. Yet nobody is alarmed by familiar ways of using alcohol to enhance our relationships. Bonding with a colleague over a post-work drink or celebrating an achievement with a bottle of champagne between friends is not seen as morally objectionable. ## Psychiatry’s problem with reductionism *Highlight [page 2]:* Psychiatry uncomfortably spans biological, psychological, and social perspectives on mental illness. As a branch of medicine, psychiatry is under pressure to conform to a biomedical model, according to which diseases are characterised primarily in biological terms (e.g. genetic influence, molecular changes in the body’s organs, abnormalities detectable via blood tests, MRI scans, etc). But psychiatry also draws on the psychotherapeutic tradition, which explains mental distress in terms of life experience and social influences. *Highlight [page 3]:* progress has been made in understanding how the brain changes when we learn (Kandel 2001); how psychotherapy changes the brain (Gabbard 2000); the link between genotype, childhood maltreatment, and adult antisocial behavior (Caspi et al. 2002); and the role of oxytocin in post-natal depression and children’s mental health (Apter-Levy et al. 2013). *Highlight [page 3]:* Nassir Ghaemi, This eclectic freedom borders on anarchy: one can emphasise the ‘bio’ if one wishes, or the ‘psycho’ … or the ‘social’. But there is no rationale why one heads in one direction or the other: by going to a restaurant and getting a list of ingredients, rather than a recipe, one can put it all together however one likes. This results in the ultimate paradox: free to do *Highlight [page 4]:* whatever one chooses, one enacts one’s own dogmas (conscious or unconscious). (Ghaemi 2009: 3) *Highlight [page 4]:* several types of reductionism. Ontological, methodological, and epistemic reductionism are perhaps the most frequently mentioned *Highlight [page 4]:* Ontological reductionism is the view that there is only one type of stuff—physical stuff—that figures in biological, psychological, and social accounts of mental illness. It entails that, if there were nothing physical in the world, there would ipso facto be nothing psychological or social either. Ontological reductionism in psychiatry is a denial of Cartesian mind-brain dualism, and is uncontroversial *Highlight [page 4]:* Methodological reductionism is the view that mental illness is most fruitfully studied by focusing on biological phenomena rather than on psychological or social phenomena. *Highlight [page 5]:* Kendler et al. (2003) show that an individual’s risk of suffering from depression is strongly linked to certain experiences, *Highlight [page 5]:* Epistemic reductionism is the view that facts expressed in psychosocial terminology can be replaced by facts expressed in biological terminology *Highlight [page 7]:* There are, then, at least three forms that reductionism in psychiatry could take. Ontological reductionism is widely accepted, whilst methodological and epistemic reductionisms are controversial. Whilst reference to reductionism is common in psychiatry, adequate delineation and evaluation of different kinds of reductionism are rare *Highlight [page 22]:* at the most fundamental level, nobody fully understands how we come to have conscious experiences, we look to psychiatrists to fix us when our ability to produce normal experiences goes wrong—when, for example, we become depressed or psychotic. Psychiatrists, then, must find practical solutions in an area where the most fundamental conceptual questions remain unanswered *Pens*