Abstract
Human enhancement, the non-medical use of biomedical technologies to improve the human body or performance beyond their ‘natural’ limitations, is a growing trend. At the same time, the use of these technologies has societal consequences. In societal debates about human enhancement, however, it is mainly the voices of experts that are being heard, and little is known about the public’s understanding of human enhancement. The views of the public can give valuable insights, and can, in turn, supplement experts’ voices in political decision-making as has been argued before for other emerging technologies. This study presents a systematic literature review of current public perceptions and attitudes towards technologies for human enhancement. Results show that the public’s view has not been assessed often. Studies originate mainly from western-oriented countries and cover a broad range of enhancement technologies. In the studies, the majority of respondents hold moderate to strong negative attitudes towards enhancement technologies for non-medical applications, although the type of technology influences these opinions. The study provides an overview of what is known about citizens’ attitudes towards technologies for human enhancement.
Keywords
1. Introduction: Individual enhancements and societal consequences
Human enhancement consists of a range of biomedical technologies that all promise to improve specific aspects of human functioning or the human body (Coenen et al., 2009; Douglas, 2009; Van Est et al., 2008). Some technologies are already familiar, such as cosmetic surgery to improve appearance, the use of doping to improve sports performances or the use of methylphenidate (Ritalin) to boost concentration. Also, newer biomedical technologies are being experimented with or considered for enhancement purposes. Pre-implantation genetic diagnosis (PGD) increases control over offspring and their genes and deep brain stimulation can stimulate mood improvement (Schuijff and Munnichs, 2012). Thus, human enhancement promises individuals a whole range of possibilities to improve traits or characteristics that someone might want to improve.
At the same time, when reaching new frontiers of science and technology, a variety of ethical, moral, and social questions and concerns arise. These regard, for example, the safety of these biomedical enhancements for healthy people, the gap between individual benefits and disadvantages for society as a whole, and issues of enhancement tourism. Such questions and concerns affect all sorts of people since we all will encounter human enhancement technologies in the future. According to Greely et al. (2008) and Hall (2004), thus far, ethical, moral and social questions raised by the use of enhancement technologies by individuals have been discussed in the literature mainly by ethicists, scientists, policy makers and politicians (see, for example, Koops et al., 2009; Swierstra et al., 2009), and have limited the debate to these experts. Several authors, therefore, have made the case to open up and broaden the debate about human enhancement and specific enhancement technologies, by including opinions of a wider public (Greely et al., 2008; Hall, 2004; Lucke et al., 2006). A broader debate about, for example, normative issues can bridge the gap between needs and concerns of both experts and the wider public (Coenen et al., 2009: 8). And, according to Nisbet and Scheufele (2009), consulting the public and meaningfully engaging with stakeholders and a wider public also helps to better understand the complex factors that shape public preferences and policy decisions surrounding science and technology.
These calls for more insight into public opinions and perceptions resonate with more generally held ideas about public participation and public engagement. Public participation, that is, engaging a wider public in science issues from the stage of agenda-setting onwards, is often seen as ideal for solving the growing gap between science and society (cf. Gibbons, 1999; Pidgeon et al., 2009; Wickson et al., 2010; Wilsdon and Willis, 2004). Gaining insight into public perceptions and attitudes helps then to better understand the science–society relationship and inform public participation processes. This has been argued as well for the case of nanotechnology (see, for example, Dijkstra and Critchley, 2014; Pidgeon et al., 2009; Wilsdon and Willis, 2004). And, as human enhancement technologies will concern us all, it is even more urgent to enhance the public debate for these emerging technologies and move beyond an expert debate.
In order to better understand current public perceptions and attitudes related to human enhancement technologies, we conducted a systematic literature review. 1 As far as we know, such a review has not been done before. A review can provide a broader overview of the variety of opinions and attitudes and what they entail. More information on perceptions and attitudes towards individual technologies for human enhancement can shed light on which technologies are most likely to have (problematic) consequences that need to be discussed or dealt with. Consequently, this can contribute to a fruitful debate about human enhancement technologies. In this article, we describe the main findings of the literature review.
2. Methods
Our systematic literature review included studies published in English in academic journals between 1998 and 2011. In addition, we searched for (unpublished) reports (grey literature). References found in the articles and reports were checked for further relevant articles or reports (snowball method). Two criteria guided the inclusion of the studies. First, the study included human enhancement in general, or, one of the four selected enhancement technologies that were studied in earlier work (Coenen et al., 2009; Van Est et al., 2008): cognitive enhancement, deep brain stimulation, (gene) doping and PGD. Second, in the study, a (broader) group of people, that is, a specific public, was asked about their opinions or attitudes quantitatively and/or qualitatively. This included various publics such as representative samples of populations (general public) and groups with specified backgrounds (e.g. students, citizens, patients, but also doctors) who are not included in the current expert debate about human enhancement.
Selection was done by three independent assessors in three rounds. In the first round, 243 articles were identified of which 43 full articles remained after assessment of the abstracts; of these, 16 articles fulfilled both inclusion criteria. In addition, via snowball method, another 50 articles were assessed, of which 15 fulfilled both criteria. In the third round, an additional search was conducted which led to an assessment of 45 abstracts and another 7 articles. In total, 38 articles were included for analysis.
After selection, opinions or views and arguments in all included articles were clustered and analysed in an iterative process. These are described in more detail below. Although the various studies are not directly comparable with each other due to the different foci and the different methods used, altogether the studies provide a broader image of what human enhancement entails for these publics. In addition, some findings shed light on, for example, differences in experts’ and citizens’ opinions. After presenting the findings of our review, we discuss the relevance of these studies for a broader public debate on human enhancement.
3. Results
Where and what about
Our study shows that a broader public’s view has not abundantly been assessed. Only 38 studies published between 1998 and 2011 satisfied both inclusion criteria. Tables 1 and 2 provide an overview of the 38 included studies. While these 38 studies were included, not all of these studies were solely dedicated to human enhancement in general or to one of the four selected technologies for human enhancement (i.e. using the technologies to improve the mind or body of healthy individuals to achieve better focus, sports performances, etc. without medical necessity). The included studies, for example, also included findings on opinions of medical applications of the same or similar technologies (i.e. using the technology to treat, heal or improve the mind or body when a medical necessity to do so has been diagnosed).
Overview of European studies with type of public studied, area of applications and research methods.
PGD: pre-implantation genetic diagnosis; GP: general practitioners; CF = cystic fibrosis; HE = human enhancement; IVF = in vitro fertilisation.
Overview of studies outside Europe and worldwide with type of public studied, area of applications and research methods.
PGD: pre-implantation genetic diagnosis; HE = human enhancement; IVF: in vitro fertilisation.
The studies were conducted in various countries worldwide, although the vast majority were performed in western-oriented countries. In Europe (see Table 1), 19 studies fulfilled the inclusion criteria. The research originated from the United Kingdom, Germany, Denmark, Sweden and Russia. Outside Europe (see Table 2), 19 studies were included. In the United States and Canada, 12 studies were conducted and in Australia 4 studies, while 2 studies were conducted in Japan. Finally, one study consisted of a worldwide survey among Nature readers (Maher, 2008). We did not find any studies performed in Southern and Eastern Europe, Africa, Latin America, or other Asian countries than Japan (Macer et al., 2007).
In some of the countries, the studies can be tied to political or academic debates held at the time (e.g. in Germany, a debate about the legalisation of PGD was going on), but in some countries where such a debate is or was happening, public opinion studies have not taken place. For example, in the Netherlands, no studies have been published which concern a wider public’s opinions of human enhancement.
Most studies (26 out of 38) presented quantitative data retrieved via questionnaires that were conducted among groups such as representative national general publics or student groups. Other data were collected via qualitative methods such as interviews, citizen panels and group discussions or a combination of methods, where opinions of specified groups or publics (e.g. citizens, patients, doctors, teachers, bodybuilders) were asked.
The studies covered a broad range of human enhancement technologies (see also Tables 1 and 2). Within Europe, the studies originating from the United Kingdom and a study partly conducted in the United Kingdom and partly in Russia, aimed at analysing various human enhancement applications, such as PGD, selection of traits, designer babies, sports doping and drug use for non-medical applications such as performance enhancement (Backhouse and McKenna, 2011; Calnan et al., 2005; Dahl et al., 2003; Edwards, 2002; Gudkov et al., 1998; Human Fertilisation and Embryology Authority (HFEA), 2003a, 2003b; Iredale et al., 2003, 2006; Monaghan, 2002). The German studies concentrated on PGD which, as said, relates to the political debate in Germany about legalisation of these technologies (Dahl, 2004; Dahl et al., 2004; Finck et al., 2006; Krones and Richter, 2004; Krones et al., 2005; Meister et al., 2005). The Danish (Møldrup and Hansen, 2006; Møldrup et al., 2003) and the Swedish research (Bergström and Lynöe, 2008) regarded studies about the drug use for non-medical applications. Outside Europe, the American studies mainly focused on selection of traits, for example, by PGD technology leading to designer babies, or on drug use for non-medical applications (Banjo et al., 2010; Bates, 2005; Gurmankin et al., 2005; Hotze et al., 2011; Kalfoglou et al., 2005; Meisenberg, 2009; Milner et al., 1999; Rabino, 2003; Sabini and Monterosso, 2005; Simpson and Edwards, 2003). Two Canadian American studies were the first to study opinions about deep brain stimulation for non-medical treatment (Lipsman et al., 2011; Mendelsohn et al., 2010). Australian research, all conducted by the same group of researchers, studied under which conditions human lifespan extension is acceptable (Lucke et al., 2006; Partridge et al., 2009, 2011; Underwood et al., 2009). Finally, Japanese research investigated selection of traits with the use of genetic technologies (Chen Ng et al., 2000; Macer et al., 2007) while the international study analysed drug use for performance enhancement applications (Maher, 2008).
Worldwide public views
Below, we discuss the studies in more detail, based on the various applications that were studied. Drug use for non-medical applications, such as concentration improvement and enhanced mood or memory, was studied in Danish, Swedish, English and American research (see Tables 1 and 2). Results showed that use of methylphenidate for concentration enhancement was more accepted than other applications such as mood enhancement. The Danish studies revealed that acceptance of methylphenidate had risen over time (Møldrup and Hansen, 2006; Møldrup et al., 2003). According to the researchers, reasons for this rising level of acceptance were more familiarity with the use for non-medical applications and associations with a certain life style. The Swedish research showed that people included the reasons for enhancement in their considerations about acceptance and people frame enhancement for social reasons more positively than enhancement for personal reasons. Also, they accepted natural enhancements more easily than enhancement through drug use (Bergström and Lynöe, 2008). The international Nature study (Maher, 2008) and American studies among students (Sabini and Monterosso, 2005) found similar results. The Nature study (Maher, 2008) demonstrated that 20% of the readers said to use concentration enhancers while 80% held the opinion that healthy people should be able to use these types of drugs. Another study showed that doctors would prescribe the drug sildenafil most frequently because the drug is well known (Banjo et al., 2010) while at the same time they doubted if these types of drugs are safe to use. There were no qualitative studies included in the review sample which could have shed light on underlying arguments for or against the use of concentration enhancers.
Pre-implantation genetic diagnostics (PGD) and other reproduction technologies have been studied in more than ten articles, both quantitatively and qualitatively (see Tables 1 and 2). In Germany, the political debate about legalisation of PGD applications inspired the studies by German researchers (Dahl, 2004; Dahl et al., 2003, 2004; Krones and Richter, 2005; Krones et al., 2005; Meister et al., 2005). In these studies, the German public supports legalisation of PGD. More specifically, the use of PGD technologies for medical reasons, such as preventing severe hereditary diseases, is widely accepted while use for selection of traits or sex for non-medical reasons is not accepted by a majority. The German public is more stringent in these opinions than the British (Dahl et al., 2003) and argues that societal consequences are difficult to foresee, life is a gift given by God and the technology reduces women to objects (Finck et al., 2006; Meister et al., 2005). Selection of sex is accepted by a small minority of British respondents only (HFEA, 2003a, 2003b; Iredale et al., 2006), while the majority considers a child not a possession and therefore rejects sex selection.
In the American studies, too, the respondents (general public and student groups) are against PGD for non-medical reasons (Gurmankin et al., 2005; Meisenberg, 2009; Milner et al., 1999; Simpson and Edwards, 2003) and are more ready to accept PGD for medical arguments. Safety is more of concern than religious or moral judgements (Simpson and Edwards, 2003). Respondents worried about changing family relations should ‘designer babies’ become common practice (Bates et al., 2005). In another study, concerns were expressed about which diseases and types of traits could be the focus of selection. This qualitative study found that support for PGD is not black-or-white, although support declines for non-life threatening conditions (Kalfoglou et al., 2005). Finally, Japanese studies (Chen Ng et al., 2000; Macer et al., 2007) demonstrated that the Japanese are more positive towards gene technologies in general compared to Western publics but are the most negative about PGD applications.
Gene doping or sport doping is studied in British research where bodybuilders were assessed about their drug use (Monaghan, 2002) while a Canadian study examined doctors’ opinions about sport doping (Backhouse and McKenna, 2011). In addition, in various quantitative studies with a general public as respondents, a few questions were dedicated to sport doping but these studies mainly focused on gene technology more broadly (cf. Macer et al., 2007). In the British study, both the general public and doctors rejected sport doping; however, bodybuilders themselves considered use of steroids to be a personal choice and opposed the general opinion that doping is not acceptable. The types of values (e.g. their concept of a good body, autonomy) they expressed indicate that the body-building community has developed its own values and norms regarding the use of doping (Monaghan, 2002).
Deep brain stimulation for enhancement purposes has not been studied often (Lipsman et al., 2011; Mendelsohn et al., 2010). Neurosurgeons and neuro-clinicians are the ones who apply this technology for medical use. In two studies, they were asked about their opinions in hypothetical scenarios dealing with surgical cognitive enhancement and expressed moral and ethical objections when changing personality traits by means of deep brain stimulation. In their view, it can cause unnatural differences in society and erodes the autonomy of the users; however, they also thought that in the future, this technology will be applied more often, for example, for fighting egoistic traits or for improvements in cognitive capacities (Lipsman et al., 2011; Mendelsohn et al., 2010).
Finally, in Australia, four studies have been conducted regarding human lifespan expansion (Lucke et al., 2006; Partridge et al., 2009, 2011; Underwood et al., 2009) in both a quantitative and qualitative way. Not all Australians supported lifespan expansion, but they approved research into this topic. Supportive respondents wanted to know more, learn more, under the condition of the same quality of life, while those opposed to lifespan expansion didn’t want ‘to play God’ and questioned population issues and pressure on welfare provisions. The studies provided a broad variety of arguments and showed differences in opinion between people with a religious or conservative background and techno-positivist transhumanists.
All in all, taking into account their limited number, the studies show that the various groups of respondents that have participated in the different studies are sometimes neutral or moderately positive towards technologies that prevent or cure diseases. A vast majority of respondents in the studies hold a moderate to sometimes strong negative attitude towards enhancement technologies for non-medical applications. Only a minority (including the so-called transhumanists) is strongly in favour of human enhancement. This last group of respondents used individualist arguments more often than the adversaries. For example, they argued that they want to be able to experience human lifespan extension themselves (Partridge et al., 2009).
Groups of respondents that expressed opinions against using enhancement technologies cited ethical, moral or social arguments. They argued that using enhancement technologies meant you are ‘playing God’ or that these possibilities objectify the human body; social arguments included the fear of discrimination, the possibility of a future ‘superbreed’ and the corrosion of ideas about individuality, natural variation and self-determination (cf. Dahl et al., 2004; Kalfoglou et al., 2005; Partridge et al., 2009). On average, the arguments against enhancement technologies outweighed the positive arguments for most respondents in most studies.
In general, gender and country of origin do not seem to influence the public’s views, but the type of technology has some influence. For example, the use of PGD and other reproductive enhancement technologies (for non-medical reasons) is assessed as extremely negative, although small groups are in favour of sex selection for non-medical reasons. Using drugs for concentration purposes is viewed more positively (Møldrup et al., 2003), although a majority of respondents in this study is against concentration enhancers. Remarkably, in one study where views of general practitioners (GP) were compared to those of a general public, the latter group was the most positive about cognitive enhancers (Bergström and Lynöe, 2008). In this study, reasons for using enhancement technologies influenced people’s opinions as the use for altruistic purposes was viewed more positive than the use for personal gain or benefit (e.g. to perform better as a doctor or to make someone a ‘better’ person; Bergström and Lynöe, 2008). Some studiessuggested that becoming more acquainted with the enhancement technology contributed to more positive outlooks (Banjo et al., 2010; Dahl et al., 2004; Edwards, 2002; Maher, 2008).
4. Discussion and conclusion
We conducted a systematic literature review in order to understand and analyse public perceptions and attitudes towards human enhancement. Insights into public perceptions and attitudes and how they are formed are helpful when facilitating a broader debate about human enhancement technologies. The findings demonstrate that a broader audience or public have not been asked about their opinions frequently. Only 38 studies, published over a 13-year period, were at least partially dedicated to human enhancement technologies.
Based on the included studies, it was possible to get more insight into the opinions and attitudes of a wider public towards human enhancement and individual enhancement technologies. As the studies have been conducted at varying times, through multiple methods with varying groups of respondents, and by different groups of researchers, the findings should be interpreted with care. Despite this, and given the lack of other review studies, we think that the literature review still contributes to a broader overview of opinions related to human enhancement technologies.
It is clear that much is not yet known about opinions and attitudes related to human enhancement technologies. Questions, such as what influence the duration of the enhancement (e.g. permanent or temporary) has on the public’s opinion; whether technologies that aim at similar enhancements are assessed similarly or differently or how societies could best regulate these technologies, have not been topic of the included studies and thus only a fragmented image was obtained. The main body of studies focused on a single enhancement technology or application (e.g. lifespan enhancement or gene doping) and thus provide little indication of opinions and attitudes towards other enhancement technologies. In several countries, where more than one study was conducted, all studies focused on the same enhancement technology. Examples are the German studies that all cover pre-implantation genetic diagnostic screening, while the Australian studies in this review studied lifespan enhancement. In addition, even though the 38 included studies have been conducted in a variety of countries, the studies were centred in particular countries (e.g. the United Kingdom, USA, Germany, Australia or Scandinavian countries) and in many other countries no studies were conducted such as most of the Eastern and Southern European countries, the South American and African continents and large parts of Asia. Noticeably, some countries where an expert debate on human enhancement is going on were not present in the review (e.g. the Netherlands). On the whole, the limited number of included studies indicates that the debate indeed appears to be mainly an expert-only debate, although in some countries some technologies have been discussed more frequently and with a wider public.
Several findings in our review stood out. First, the range of the used arguments provide interesting knowledge about differences between experts’ and non-experts’ opinions. Some studies show that emphases are placed differently by these two groups. For example, in a study comparing experts’ views and those of the general public, Krones et al. (2005) found that they held different opinions on using PGD for the selection of desired traits in a future child even though both groups agreed on the use of the same technology to prevent severe hereditary genetic disorders. Second, findings showed that attitudes had changed in the instances where it was possible to compare attitudes of respondents over time. Third, the reviewed studies indicate the division of proponents, adversaries and people holding middle grounds in society. They also hint at the potential (un)popularity of different enhancement technologies, which might help to prioritise and define issues for societal debate, possible policy directions, and political decision-making.
This review provided insight into publics’ attitudes and opinions. In our view, an expert debate that simply includes these opinions is not enough, we make a plea for more active participation of a broader audience in debates about human enhancement. Recent focus group research with non-experts on human enhancement technologies demonstrates that, compared to expert debates, non-expert debates more often include personal experiences and participants acknowledge that their opinions can change over time (Schuijff and Munnichs, 2012). This insight into the dynamics of citizen deliberation indicates that the social debate should focus on specific cases of enhancement technology (Schuijff and Brom, 2013). Assessing public attitudes and opinions via representative public opinion studies is useful and should be included into a societal debate, but such findings are not able to replace citizens’ views, reasoning and opinions expressed in the debates themselves. Additionally, giving citizens the opportunity to contribute to societal debates can empower them to become a more engaged and active public (Wickson et al., 2010). Consulting a public, by asking them to contribute to a public opinion study might do this to a lesser degree.
In conclusion, we believe that including opinions of a wider public can contribute to a broader and more meaningful societal debate on human enhancement technologies. The findings of this review study shed more light on the variety of opinions and arguments and thus people’s positions and arguments. Including those opinions, assessed by both quantitative and qualitative data can, for example, bring in the needs and concerns held by other groups in society (Coenen et al., 2009). Therefore, we advocate moving beyond the expert-only debate and letting the public participate in issues of human enhancement technologies (Hall, 2004; Wickson et al., 2010). On the condition of early involvement, a broader debate will, among others, lead to more responsible and more democratic decision-making (Wilsdon and Willis, 2004), and actively engaging publics will help to shape human enhancement technologies to meet social needs and accommodate plural values (Wickson et al., 2010). Furthermore, not only is a debate needed as the case of biotechnology in Europe has shown (Gaskell and Bauer, 2001; Pidgeon et al., 2009), but such a debate will also be appreciated by a general public. Broadening the debate on human enhancement in deliberative democracies by including citizens and other publics also could be helpful in moving beyond the intractable disagreement that often has characterised debates on biotechnologies in the past, because it can benefit the formation of opinions among participants such as citizens (as future stakeholders) who might voice different perspectives (Bovenkerk, 2012).
Efforts to organise nanotechnology participatory activities show us that a broader public is interested in new technologies (as was shown in the Dutch public debate on nanotechnology in 2010). In addition, past studies revealed that a general public is able to contribute to the debate in a useful way, although publics will not always participate when offered the possibility (Dijkstra and Gutteling, 2012). Publics in some roles want information to be available, while in other roles want to get involved in decision-making processes.
Therefore, more insight is needed to understand what publics think about human enhancement and its applications and how they would prefer to participate. Using qualitative studies can give insight into the arguments people hold, while, at the same time, quantitative research shows which opinions or arguments are most prevalent and how many people would like to use enhancement technologies, and may indicate how these attitudes are formed and possibly changed. More knowledge about people’s views and how these are formed or transformed will, in the end, lead to more socially robust development of human enhancement technologies that will affect us all.
Footnotes
Acknowledgements
The authors would like to thank Martijntje Smits and Geert Munnichs for their help during the project and Frans Brom for comments on earlier drafts. We gratefully acknowledge the suggestions of two anonymous reviewers.
Funding
This research was funded by the Rathenau Institute as part of a larger project on Human enhancement.