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You cannot have your normal functioning cake and eat it too
  1. Michele Loi1,2
  1. 1Center for Translational Genomics and Bioinformatics, San Raffaele Scientific Institute, Milan, Italy
  2. 2CeSEP, Università Vita-Salute San Raffaele, Milan, Italy
  1. Correspondence to Dr Michele Loi, Center for Translational Genomics and Bioinformatics, San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milano, Italy; loi.michele{at}


Does biomedical enhancement challenge justice in health care? This paper argues that health care justice based on the concept of normal functioning is inadequate if enhancements are widespread. Two different interpretations of normal functioning are distinguished: the “species typical” vs. the “normal cooperator” account, showing that each version of the theory fails to account for certain egalitarian intuitions about help and assistance owed to people with health needs, where enhancements are widespread.

  • Allocation of Health Care Resources
  • Concept of Health
  • Distributive Justice
  • Enhancement
  • Genethics

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By human enhancement, bioethicists mean improving our bodies, minds or abilities through technology, in particular, biotechnology. For instance, some prescription drugs, such as methylphenidate (commercialised as Ritalin), are used by healthy people to improve their academic performance.1

One prominent issue is whether healthcare ought to include enhancements, not only therapies, as a matter of justice. According to Daniels’ ‘normal functioning’ approach,2 diseases, characterised as departures from species-typical functioning, restrict opportunities in an objectively specifiable manner. Preventing and correcting diseases, not enhancing human capacities, ought to be the primary rationale of healthcare.

Daniels argues that his approach provides the best moral explanation of the egalitarian belief that citizens owe each other help and assistance by way of meeting each other's health needs. But the view that publicly subsidised healthcare ought to include enhancements, beside therapies, gains credibility by considering a possible future in which certain human enhancements will be widespread. Imagine that many people are genetically enhanced before conception to achieve perfect sight or a greater resistance to common infectious diseases. Those excluded from enhancements would face a threat of social exclusion comparable with those faced by persons with disabilities in societies where their different needs are not met.3 ,4

This essay evaluates how different versions of the normal functioning approach deal with this potential objection. It is argued that though the concept of ‘normal competitor’ and ‘species-typical functioning’ are liable to be confused, the two concepts have different implications.3 Hence proponents of the normal functioning view face a dilemma: if they ascribe moral importance to ‘being a normal cooperator’, they face one set of objections, while if they ascribe moral importance to ‘species-typical’ functioning, they face another one.

Reasons in favour of the species-typical normal functioning view

Norman Daniels’ approach can be defended by showing that it is an extension of Rawls's principle of fair equality of opportunity, which requires that we mitigate class-effect from life chances by equalising people's social circumstances. According to Daniels, health is a strategic good, influencing access to other social primary goods attached to careers. Hence, opportunities are fair only if impairments of normal functioning are eliminated, where possible. If we implement justice in healthcare, we approach the original idealisation underlying Rawls's theory, namely, that we are concerned with normal, fully functioning persons.2

Daniels concludes that fair equality of opportunity is the most plausible rationale for sharing the costs of healthcare; conversely, health needs should be identified with opportunity-reducing departures from normal functioning. Daniels also offers an argument by comparison, as he raises several objections against alternative views of justice and health, some of which I will argue to be more persuasive than others. The following positions are discussed by Daniels in his writings.

Welfarism about justice in health

By this I mean the view that help and assistance is owed to sick and disabled individuals as a matter of justice, because their welfare level is very low on an absolute scale (prioritarian version) or lower than that of most other people (egalitarian version). Against this view, Daniels notes that many sick and disabled persons appear to adapt to their pathologies, so that their welfare is no less than it had been before the onset of pathology and/or no less than the welfare of others who lack the pathology. But, arguably, people who adapt very well to pathological conditions should not be considered, for that reason, less entitled to resources meeting their health needs.2 Conversely, we want to avoid making egalitarian justice hostage of the expensive tastes some people may develop.2 This was also a key point made by Sen in favour of his capability approach.5

This argument offers very limited support to Daniels’ view. It only applies to welfare conceived as a subjective state (eg, pleasure or desire-satisfaction). If welfare is constituted by objective goods,6 or capabilities, P may be better off than Q even if Q is happier or more satisfied with her condition than P, and vice versa. Let us therefore consider his arguments against capability sufficientarianism and luck egalitarianism that have broader implications.

Capability sufficientarianism

This is the view that citizens’ duties of health protection and prevention require, as a matter of justice, guaranteeing capabilities above a minimal threshold. Daniels objects that the view does not specify any non-controversial, non-arbitrary threshold of abilities, unless it refers to species-typical functioning, as objectively specified by the natural sciences. If on the contrary such account is presupposed, capability sufficientarianism converges with Daniels’ account in practice.2

Luck egalitarian justice in health

This is the view according to which (A) citizens ought to, as a matter of justice, aid the unfortunate and (B) the misfortune that is supposed to trigger the obligation to aid is misfortune for which people are not responsible.7 This view is argued to be socially divisive, because people differ in the extent to which they hold other people directly responsible for their ends and attainments and the relevant information is anyway difficult if not impossible to obtain.2

Daniels’ rejection of both luck egalitarianism and capability sufficientarianism emphasises the need for public objective criteria, to specify clearly and uncontroversially the scope of justice in healthcare. Conversely, Daniels’ positive argument relies on the prima facie plausible claim that ‘the natural baseline (of normal functioning) has become a focal point for convergence in our public conception of what we owe each other by way of medical disease or health protection’.2 Summing up, the objectivity of normal functioning is deemed essential to political agreement concerning the limits of citizens’ duty to meet each other's health needs.

Notice the importance of Daniels’ appeal to agreement in support to naturalistic conceptions of normal functioning. It allows me to pre-empt a potential objection against the present paper. Arguably, some of my arguments show that Daniels cannot appeal to Boorse's view,8 ,9 but maybe other ways of filling in the details of the species-typical functioning conception are not equally vulnerable to them.

This defence overlooks an important feature of the justification of the normal functioning approach, namely the requirement to promote agreement. This requirement commits Daniels to rejecting views of the disease concept as fundamentally evaluative, that is, entirely reducible to the concept of a bad or unsatisfactory life. That would make the limits of healthcare depend on quality-of-life judgments concerning which reasonable people disagree. Moreover, it commits Daniels to assuming that different naturalistic views converge ‘on nearly all judgments about normal or abnormal functioning’. In this way, potentially endless controversies concerning the details of such views can be sidestepped for practical purposes.2

The important point is that Daniels needs to claim that all plausible naturalistic accounts converge for a vast range of cases. If there is no single ‘natural’ baseline, the choice of a natural baseline should rely on potentially controversial normative considerations, contradicting Daniels’ rationale to rely on a natural baseline in the first place. Since the natural baseline ought to be unique, other ways of filling in the details of the species-typical conception should have similar implications for the therapy/enhancement distinction. If so, they will be equally vulnerable to the objections below.

Reasons against the species-typical normal functioning view

According to Daniels’ approach, no deprivation of physical, mental and social well-being qualifies as a health need, unless it is also a departure from normal functioning, naturalistically specified.2 Even enhancement deemed necessary for certain careers, such as aesthetic breast enlargement, are not included in the ‘primary rationale’ of healthcare. Small breasts are not health needs, because they cannot be classified as departures from normal functioning in biomedical terms.2

This account of health justice appears inadequate in a scenario in which normal or healthy people, according to biomedical criteria, are at a significant disadvantage compared with the rest of the population. Consider a society in which some biotechnological enhancement, that is, a gene delivering greater resistance to disease, is widespread. Buchanan et al write that: if enough people were able to afford such enhancement … those who lacked access to the enhancement would be significantly disadvantaged—indeed, might come to be regarded as disabled—even though they were perfectly normal by our present, pre-enhancement standards (p. 97).3

People without genetic enhancements of the immune system may be excluded from jobs requiring a genetic enhancement certificate. If the species-typical account of normal functioning is adhered to, the social provision of enhancements is not justified as part of a duty to meet the health needs of a population. Daniels may respond by conceding that some enhancements may be justified on a case-to-case basis in the name of a broader conception of equality of opportunity.2 But this broader conception is unlikely to resonate with as great a variety of moral views, as the duty to meet health needs. Very likely, groups excluded from enhancements have reduced access to the political forum, so enhancement subsidies are unlikely to be approved, unless they repay themselves in the relatively short term.

The general point is that the level of functioning that matters for equality of opportunity depends not on what is typical in the species as a whole, but in the society in which one lives. Disabilities are conditions preventing individuals from developing or exercising abilities to participate in cooperation and the relevant abilities are determined by the ‘dominant cooperative scheme’.3 This justifies a ‘normal-competitor’ account of health-related duties of justice, according to which the primary role of healthcare is to ensure that all citizens be able for social cooperation in their actual social historical circumstances. In a society in which enhancements are widespread, normal abilities may be enhanced ones.

Are the normal-competitor and the species-typical view compatible?

Buchanan et al also seem to claim that even in a future enhanced society the normal-competitor and the species-typical view of normal functioning converge, since: it is conceivable that genetic enhancements of normal human functioning, if sufficiently available and widespread, might lead us to revise upward our conception of normal species functioning, with the result that where we draw the line between health and disease, and hence between enhancement and treatment, would correspondingly change. (p. 98).3

I will now argue that this claim invokes a ‘presentist’ analysis of normal functioning, that is, a view that takes into account the capacities of only present humans, which is incompatible with the Boorsian and, perhaps, also the biomedical one.

Roughly speaking, Boorse's definition of health8 ,9 states that a part or process of an organism is healthy when it functions normally for that kind of organism. The function of that process or part is defined by its statistically typical contribution to the survival and reproduction of all organisms belonging to the same species of the same sex and age group. First, notice that the concept of a statistical norm lacks any real meaning unless one specifies the population under examination. The statistical norm of lymphocytes in the AIDS-infected population is different from the statistical norm in the general population. The relevant population in Boorse's account is the entire human species, the only further relativisations being to sex and age. The relativisation to sex and age is necessary, in order to account for the fact that what we call a process or part of a healthy female organism at age two may differ, functionally or morphologically, from the same process or part in a healthy female organism at age 40, as well as from its male counterpart. But what does ‘the entire human species’ mean?

Suppose it means ‘all presently existing humans’. As a majority of the world population is born with enhanced genes, those capabilities become statistically normal and, thus, species-typical in the required sense. As the threshold for cooperation goes up, so does the statistical value defining health needs.

Even if the presentist and the normal-competitor account converge, the presentist account is not the Boorsian one: I do see a species as extending over time as well as space, so for me some of the past affects what is species-typical. I do not take sudden or temporary changes in lifestyle, even if worldwide, as changes in the nature of the species. (p. 66).9

Notice that the choice to include all past and present members of the species is not ad hoc stipulation, but justified for the sake of ensuring a better fit between the biostatistical account and textbook classifications of disease. According to the biostatistical theory, billions of humans who lived from the Pleistocene to the nineteenth century, and those currently alive, count equally in defining what species-typical functioning is. The normal causal contribution of the preference for fatty and salty food is to improve survival and reproduction in the historically prevalent environment in which salt and sugar are scarce, even if in contemporary affluent societies it increases the likelihood of disease and reduces the lifespan. Yet, the desire is not usually classified as a disease, as the Boorsian theory including past and present members of the species correctly predicts.

We are now in a position to see why the convergence between the Boorsian and the normal-competitor account does not occur. While the threshold for being a ‘normal competitor’ may ratchet up according to presentist definition, species-typical functioning, as defined by Boorse, will adjust more slowly, because the relevant statistics reflect the characteristics of past members of the species. Enhanced human functions, even when statistically normal for contemporary humans, are diluted as an effect of a non-enhanced human past.

This argument shows that even if the presentist account of species-typical functioning converges with the normal-competitor view, the presentist view is not the Boorsian view. Thus the Boorsian view is objectionable from the point of view of the normal-competitor view.

Reasons against the presentist view

One possible conclusion is abandoning the Daniels/Boorse account, since it falls prey to the normal-competitor objection. Should one adopt the presentist or the normal-competitor account, instead? In the last two sections of this essay, I would like to point at potential difficulties that have to be solved.

The Boorsian view can be argued to achieve the best fit with the usage of the disease concept in theoretical medicine and physiology. According to Daniels, the physiological usage is the cornerstone of public agreement, that we risk to threaten, if we adopt an alternative account. Suppose, moreover, that presentism leads to classifying the lack of enhanced abilities required by cooperation as diseases, thus avoiding the enhancement objection. If so, the question arises which account, the Boorsian or the presentist one, ought to be binding for political purposes. As pointed out in the section Reasons in favour of the species-typical normal functioning view, if more than one natural baseline exist, the fact of relying on a baseline that is natural cannot be invoked as an advantage of the normal functioning account.

For similar reasons, Daniels should also reject another account of what is species-typical, one including all present, past and future members of the species, even if the future effects of present genetic enhancements are presently predictable.

Second, the presentist view and the normal-competitor accounts do not necessarily converge. If global inequalities persist, the threshold of cooperation may ratchet up in wealthier but less densely populated regions. Some unenhanced human born in advanced societies may be excluded from social cooperation, even if they are normal-relative to the present species standard (reflecting the most common condition). Since their ability to cooperate is also constrained by linguistic and cultural factors, there might be no accessible cooperation scheme to which they can take part. Hence, the threshold of normal competition may be regionally as well as temporally defined. If so, the presentist definition of health needs is still vulnerable to the objection of failing to guarantee adequate cooperation opportunities.

Reasons against the normal-competitor view

Should health needs then be defined relative to normal competition, temporally and regionally defined? I can see one problem with this solution, that I shall present through a thought experiment.

Imagine a society involving a minority, intellectually gifted ruling class, designing and controlling all technological production and policy, cooperating in very unequal terms with an underclass confined to machine-aided routine jobs in the service sector. Suppose that the intellectual abilities of the underclass, affected by nutritional deficits, are equivalent to those of mildly mentally retarded persons.

By relying on the Boorse/Daniels’ account of health needs we rejected, we can judge such society as one that does not meet the health needs of most citizens. It is not so clear whether the same is true if one assumes the normal competitor account. Suppose that the vast majority of the cooperating population belongs to the underclass. If the normal competitor is the statistically average worker in that society, members of the underclass are healthy, so privileged members of society do not owe them anything by way of health protection and promotion. If, on the other hand, the threshold for normal competition is defined by relying on a normative conception of human capacities or social cooperation, then again we face the problem of securing an objective basis for public agreement. A normativistic normal competitor account has no advantage over theories avoiding all appeals to normality, in terms of independence from controversial value judgments.


The article highlights the differences the species-typical and the normal-competitor views of normal functioning by describing circumstances in which they have different implications for the societal duty to meet people's health needs. It is also argued that each view fails to account for certain egalitarian intuitions about help and assistance owed to people with health needs.


The author wishes to thank Tom Douglas and Christopher Wareham, as well as two anonymous referees, for their help and suggestions.


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  • Funding Italian Ministry of University and Education, grant no. FIRB 2006 codice progetto RBNE063ZN8.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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