Is considerable life extension an enhancement?

Abstract

The purpose of this paper is to look into the question of whether considerable life extension should be seen as a form of human enhancement. Human enhancement, generally, refers to enhancing physical, psychological, and moral human capacities beyond the average or “normal” level. Much of the recent literature focusing on considerable life extension has been related to the human enhancement debate. I will examine whether considerable life extension and human enhancement are connected. I argue that they are not connected to each other in the way that is presented by many philosophers such as John Harris, Nick Bostrom, and Nils Holtug, as well as Savulescu, Kahane, and Sandberg. Sometimes considerable life extension should be seen rather as a part of preventive care. Considerable life extension can result simply from preventive care. If we define considerable life extension as enhancement, it is interesting because it is related to many ethical questions. A quite common view, for example, is one that states that treatment should be supported financially (at least, partly) by society, whereas enhancement should not. However, claiming that there is no strong conceptual link between considerable life extension and enhancement does not mean that the former should automatically be covered by public healthcare or insurance policies. The aim of this paper is not to present a strong view for or against the ethical desirability of considerable life extension. I argue that the importance of the human enhancement framework has been overstated in the case of considerable life extension. My point is simply that it is unclear why the possibility of radical extension in human life should be primarily discussed in the sphere of human enhancement.

Keywords:

• considerable life extension
• bioethics
• human enhancement

1. Introduction

The purpose of this paper is to look into the question of whether considerable life extension should be seen as a form of human enhancement. Human enhancement, generally, refers to enhancing physical, psychological, and moral human capacities beyond the average or “normal” level. Considerably extending human life has aroused much scientific and academic interest. One prominent field of research is, for example, regenerative medicine that aims to create tissues and organs in order to repair damage caused by illnesses, injuries, and aging. Much of the recent literature focusing on considerable life extension has been related to the human enhancement debate. I will examine whether considerable life extension and human enhancement are connected. I argue that they are not connected in the way that is presented by many philosophers such as John Harris, Nick Bostrom, and Nils Holtug, as well as Savulescu, Kahane, and Sandberg. Sometimes considerable life extension should be seen rather as a part of preventive care. Considerable life extension can result simply from preventive care.

Considerable life extension can be seen as a way to prevent serious aging-related diseases and disabilities. To state that, this does not presuppose that considerable life extension, as such, is an important goal for medicine or for society on a more general level. Even though many philosophers categorize considerable life extension as human enhancement, they do not claim that all (radical) life-extending measures would be necessary for enhancement. I argue that the importance of the human enhancement framework has been overstated in the case of considerable life extension. My point is simply that it is unclear why the possibility of radical extension in human life should be primarily discussed in the sphere of human enhancement. It is often said that public healthcare should not cover enhancements, especially in their most extreme forms. However, claiming that there is no strong conceptual link between considerable life extension and enhancement does not mean that the former should automatically be covered by public healthcare or insurance policies. Defining whether something is enhancement or not is only one aspect of determining whether it should be part of public healthcare.¹

2. About considerable life extension

What, precisely, is meant by considerable life extension? There are various ways of understanding considerable extension of human life: radical life extension, anti-aging medicine, lifespan extension, and so on. The market for anti-aging products is enormous, and youth and activity are widely admired in many parts of the (Western) world. However, considerable life extension is not equivalent to the use of anti-aging products that aim to prevent signs of aging on a cosmetic level, since cosmetic changes have no effect on the process of aging as such. Considerable life extension involves manipulating aging in the later stages of human life. Extending the average length of human life beyond the current maximum of c.120–125 years requires technologies that enable manipulation of the biological process of aging (senescence), which currently takes place in the later stages of every human being's life. Considerable life extension, in this paper, should be understood as life extension that, by manipulating the process of senescence (or, hypothetically, by some other way), leads to the kind of notable increase in human life that has not so far been possible by means of medicine. It does not mean helping people to lead a healthy life until the age of 120 but rather helping people to live tens or, perhaps, eventually hundreds of years more than the current maximum age.

It is also useful to make a distinction between extending life by hundreds of years via technological means and extending life via social and political strategies. By improving basic healthcare, it is possible to remarkably increase life expectancy in a society. Perhaps the most important factor that has led to the increase of life expectancy globally in the twentieth century was the decrease in child mortality. After the 1950s, the incidence of under-5 mortality throughout the world fell by 70% (UN World Mortality Report, 2011, p. 12). It is often pointed out that life expectancy in the world has risen rapidly. The possibilities provided by new and emerging technologies seem to enable us to maintain this rate. About 60 years ago, we lived on average 20 years less so if we can maintain this rate, especially if we consider the exponential nature of technological developments, we might very soon be living to 300 years, might we not? Although it may be tempting for many to agree, the answer seems to be no – at least in the sense that there is actually no continuum between the decrease in child mortality and the development of extremely high-level medical technology. The decrease in child mortality rates has been strongly influenced by political will, not the development of high-tech medical applications. Obviously, this does not mean that technological development cannot be fast. However, if it is, and it enables us to live extremely long in the near future, this development does not necessarily derive from the factors that led to the decrease in child mortality rates.

Prominent fields of research related to considerable life extension include, among others, regenerative medicine, nanotechnology, stem cell research, dietary restriction, and research on telomeres.² The biological aging process is studied in order to better understand and manipulate the aging mechanism and severe aging-related diseases such as Alzheimer's. Thus, there is not necessarily a clear distinction between scientific research that aims to cure aging-related diseases and scientific research that is aimed at considerably extending human life, or that is actually on a mission to considerably extend human life. The motivation for research, however, may differ greatly and is relevant for the ethical implications, even though the scientific results may not always reveal anything about the motivations.

Critics of efforts to radically extend human life might base their arguments on moral grounds or purely empirical notions. For example, Leonard Hayflick, an expert in the biology of aging, has said that before we can manipulate the aging process we certainly need to understand it better. He points out four differences between aging and disease. He writes:

Unlike any disease, age changes (1) occur in every animal that reaches a fixed size in adulthood; (2) take place in virtually all species; (3) occur in all members of a species only after the age of reproductive success; and (4) occur in animals removed from the wild and protected by humans even when that species has not experienced ageing for thousands or even millions of years. (Hayflick, 2000a, p. 267)

Hayflick's view can be separated from the approach of, for example, Aubrey de Grey, a biogerontologist and a well-known supporter of life extension. According to de Grey, we should aim to abolish aging and even death. Interestingly, even though many philosophers writing about life enhancement use de Grey as an example, he does not really particularly equate considerable life extension with enhancement. He asks why is it that we do not invest more resources in tackling aging since it can be compared to other main causes of death.³

Many philosophers have written about considerable life extension as a form of human enhancement. Gaia Barazzetti (2011, p. 338) has noted that extending the average length of life is generally considered a form of enhancement. Nils Holtug (2011, p. 139) mentions life extension as enhancement and notes that extending our life to, for example, 150 years, is not an operation that we would usually consider as treatment. Books on human enhancement that also consider questions about considerable life extension include Enhancing Human Capacities edited by Julian Savulescu, Ruud ter Meulen, and Guy Kahane (2011), and Enhancing Evolution by John Harris (2007). What is specifically meant by enhancement differs. Generally, the debate on considerable life extension focuses especially on the ethical evaluation of the possibilities provided by new and emerging technologies.

Many papers on considerable life extension refer to statistics about the increase in life expectancy. According to the United Nations (UN), the average life expectancy at birth at the world level has increased by more than 20 years over the last 60 years (UN World Mortality Report, 2011, p. 4). The development of medical technologies enables us to live longer and longer, but the downside is that people live longer and longer periods with diseases, or otherwise in a weak physical condition. It is not clear at all (and probably was never so) whether life expectancy can be seen as a good indicator of well-being in a society. Since life expectancy has risen throughout the world, both in the so-called developed and developing countries and areas, data on mortality are no longer a particularly effective way to measure people's health (Payne, 2006, p. 153).

Over the past few decades, the World Health Organization (WHO) has started to measure the healthy life expectancy (HALE), which aims to measure the number of years that a person can be expected to live in “full health”; the WHO defines it as the “average number of years that a person can expect to live in ‘full health’, taking into account the years lived in less than full health due to disease and/or injury”.⁴ HALE has not been increasing as fast as the life expectancy in general and, currently, HALE statistics are often used to compare and evaluate well-being. Based on the quite recent Global Burden of Disease Study, 2010 (published in 2012), for example, it has been suggested that HALE will be a particularly good measure of health in the future (Salomon et al., 2012). In this context, it is perhaps useful to point out that the supporters of considerable life extension do not desire extra years as such but they specifically wish to be able to lead a healthy, vital life for a long period of time. In that sense, measuring HALE would be relevant for them in order to find out how many healthy years have been, on average, added to our life expectancy recently. Of course, we should also remember that, even though we prefer health to sickness, a healthy life does not always equate to a good or a meaningful life. Neither does living with a disease mean that life would be meaningless or lack happiness or well-being.

For philosophers, it is important to note that aging should be separated from getting older. Every day, I grow older: today I'm older than yesterday, tomorrow I will be older than today, and so on. This also applies to all other living organisms and non-living things as long as they exist. Aging, on the other hand, is a biological process that is a characteristic of human and non-human animals. Therefore, when discussing considerable life extension, we are clearly talking about slowing down or preventing aging, not getting older.

3. Human enhancement and the treatment/enhancement distinction

What is meant by human enhancement? Simply put, it means enhancing human capacities beyond average level. Enhancement can also be defined in relation to treatment (which aims to cure diseases, not enhance capacities), as we will see by the treatment/enhancement distinction. There are various reports about human enhancement, and the definition is by no means clear.⁵

Savulescu, Kahane, and Sandberg support a so-called welfarist definition of human enhancement. According to their definition, this entails changes in biology or psychology that “increase the chances of leading a good life in the relevant set of circumstances” (Savulescu, Sandberg, & Kahane, 2011, p. 16). This definition is useful especially in the sense that it emphasizes the connection between a good life and enhancement; enhancement is understood in a holistic sense (improving human life in general) rather than as improving a certain capacity. The downside is that the concepts of well-being and a good life are known to be hard to define precisely – or sometimes even vaguely. When thinking across gender, cultural, religious, and ethnic borders, it becomes harder and harder to define commonly accepted (medical) goals or methods.

Of course, Savulescu et al. do not, in their definition, require committing to a specific notion of a good life or well-being. However, this also means that the threat of cultural relativism exists at the other extreme; to generalize, whatever is found as contributing to a good life (on a biological or psychological level) in the relevant set of circumstances, is enhancement, no matter what your concept of good life is. But as Savulescu et al. were probably very well aware, we do not want to embrace any conception of a good life as justification for medical enhancement (think, for example, of the Nazi espousal of eugenics). As for considerable life extension, it seems that it is possible to live very long without a specific desire to do so, in which case, living long does not necessarily meet the criteria of enhancement. Living extremely long might not be one's idea of increasing the chances of leading a good life, although this need not be the case.

There has been a lot of discussion about the distinction between treatment and enhancement among bioethicists. It is relatively widely accepted that, roughly, treatment aims to maintain our “normal” health and functioning whereas enhancement aims to literally enhance human capacities beyond the level we consider as normal. Enhancement can also refer to increasing a person's capacity (memory, for example) to a normal level when he or she is not suffering from an actual disease. As is quite obvious, the concepts of treatment, enhancement, normality, and health are very hard to define in any comprehensive manner. However, we can quite easily agree that living to 75 years is considered normal (in Western countries) but living to 750 years is not.

Erik Parens has identified two ways of distinguishing enhancement. First, in relation to medical goals, and second, in relation to society's goals. The first scrutinizes the aims of medicine and the definition of health and sickness. This kind of conceptual clarification is important in order to be able to make decisions that consider, for example, what kinds of treatments should be included in the sphere of public healthcare (as in the case of North European countries) or health insurance (as in the case of the USA). When approaching enhancement from the societal point of view, the emphasis is more on the values of a particular society and the moral choices of the individuals (Parens, 1998, p. 3).

Norman Daniels supports the view that diseases and disabilities are departures from normal functioning. According to Parens (1998, p. 3), Daniels's view represents a so-called “hard-line” conception of health, where health is seen as a state of comprehensive physical, mental, and social well-being. However, medicine is not capable of creating or maintaining such a state, and this is not required by the normal function model. In Daniels's opinion, it is acceptable that people are born with different capacities and gifts: medicine should not aim to make everyone identical. Instead, it is important that medicine aims to provide everyone with equal possibilities for upholding their normal functioning.

According to Daniels, the treatment/enhancement distinction is not without problems but can still be useful to a certain extent. He emphasizes that the distinction does not provide any clear guidelines for distinguishing between obligatory and non-obligatory or permissible and impermissible healthcare measures (Daniels, 2000, p. 309). Even though enhancement is often excluded from public healthcare, there are cases where it seems reasonable that public healthcare should cover measures that are not defined as treatment. Abortion, for example, is not a treatment by definition since pregnancy is not a disease – yet abortion is accepted as part of public healthcare in many countries. Whether we accept abortion is determined not only by medical reasons but also by cultural ones, such as respecting a woman's right to choose and giving priority to the mother's health. On the other hand, abortion does not seem to be a type of enhancement, either.

According to Eric Juengst (1998, p. 29), debates on enhancement should involve discussing both the proper limits of biomedicine and some “moral signposts” for personal decisions about improving oneself. Holtug points out explicitly that enhancement does not aim to cure or prevent diseases. In his view, enhancement aims to affect non-disease-related (genetic) factors (Holtug, 2011, p. 137). Even though he criticizes the distinction between treatment and enhancement, he says that considerable life extension is an example of something that we would not usually regard as treatment (p. 139). On the other hand, Harris and Bostrom, for example, are not very interested in the normative consequences of defining the distinction. This is somewhat problematic since a general aim of the enhancement debate seems to be creating arguments to the benefit of healthcare professionals, decision-makers, and citizens in real-life decision-making situations. Of course, it is possible to scrutinize enhancement as a purely theoretical concept that is not directly applicable outside philosophy. However, it is quite clear that Harris and Bostrom are taking part in societal discussions. They have adopted a positive attitude to enhancement and are interested in the real possibilities provided by new and emerging enhancement technologies.⁹

Both Harris and Bostrom accept that, in the context of life extension, preventive measures can also be seen as enhancement. Of course, this does not, in itself, imply that all forms of considerable life extension would be an enhancement. If considerable life extension was a side product of treatment or prevention, which Harris and Bostrom accept, it is possible that there would exist no means of considerable life extension that would not be categorized as treatment or prevention. If this is true, it is not completely clear what is the additional value brought to the ethical discussion on considerable life extension by the enhancement context. Namely, we may discuss the ethical desirability or acceptability of considerable life extension, regardless of whether or not we join the enhancement debate. There can be, of course, different motivations for living long; in the future, some people could live extremely long lives because that has become normal, yet others might consider it of greater importance to enjoy life for as many years as possible. Therefore, one could claim that the latter is a form of enhancement. Even though the situation it is not very different from the one we are currently facing.

4. Treatment, enhancement, and preventive measures

Considerable life extension is often understood as a form of human enhancement. If we define considerable life extension as enhancement, it is interesting because it is related to many ethical questions. A common view, for example, is that treatment should be supported financially (at least in part) by society, whereas enhancement should not. According to this view, public healthcare should cover the treatment of flu but not of plastic surgery arising from one's dissatisfaction about one's own appearance. It is worth bearing in mind that whereas some enhancements or other kinds of non-therapeutic measures, such as abortion, are included in healthcare, others are not.

It is not my intention to claim that considerable life extension is equal to plastic surgery operations based on “superficial” concerns. Rather, I would like to point out that even if the treatment/enhancement distinction is a helpful tool for healthcare decision-making, numerous cases exist that do not fit neatly into this distinction (by no means an original observation). In addition to the treatment/enhancement debate, there are various reasons why something should be covered by the public healthcare system. Take the case of abortion, for example. In countries where abortion is allowed, justification for allowing abortion is not so much based on the means of committing abortion, but rather on the fact that many societies tend to give a lot of value to a woman's autonomy and health.

As mentioned earlier, what is meant by enhancement varies. Generally one might say that enhancement refers to notable changes in human capacities, especially those improved by new and emerging technologies. Some capacities can be increased considerably beyond the norm by using methods that are not considered an enhancement. For example, there has been discussion over the past few decades as to whether severe malnutrition in infancy can weaken the development of intelligence.⁶ In a society where children suffer from malnutrition, it would not be reasonable to try to increase the children's intelligence by designing expensive biotechnologies to raise their cognitive capacities. It would make more sense to ensure adequate nutrition and a safe social environment for the children. Accordingly, it would not be reasonable to prioritize the development of regenerative medicine, which could increase life expectancy in a society where there are severe shortages in basic healthcare and where the under-5 mortality rates are high. It is also possible to consider “traditional” methods, such as educational methods, as enhancement. However, this is reasonable only when they aim to make people more intelligent than average, for example, and not when they aim to help people reach average intelligence levels. To avoid misunderstanding, one should state that using existing, non-enhancement methods would not necessarily rule out at the same time the development and use of new and highly advanced biotechnologies.

Sometimes a human capacity is improved, without being the consequence of a prior intention to improve it. Considerable life extension could, in theory, be a “side effect” of the efforts to understand and cure aging-related diseases, as has also been noted by Harris (2007, p. 64). He pointed out that since the distinction between enhancement and treatment is not clear, many treatments can be seen as forms of enhancement. Vaccines are a typical example of preventive measures. Harris states that they can be defined as enhancement, and he mentions that many treatments and measures for preventive care are necessarily forms of enhancement. In opposition to what he claims are Daniels's views, he maintains that treatment and enhancement are not mutually exclusive concepts.

However, Daniels seems to be well aware that the distinction is not without problems; in some cases it is extremely difficult to draw the line between treatment and enhancement. It is also good to keep in mind that Daniels is concentrating on issues of social justice, which partly explains the emphasis he puts on the political implications of the distinction. It might be nearly impossible to draw a clear conceptual line between enhancement and treatment. In practice, however, healthcare professionals, insurance companies, and politicians need to be able to define what kinds of services are included in public healthcare and are covered by health insurance policies. Even a rough conceptual distinction may be useful in order to help to create guidelines for such decision-making processes.

Harris, for example, agrees that preventive methods can be enhancement. If we accept this kind of a view, categorizing considerable life extension as enhancement is compatible with my claim that considerable life extension is a preventive measure. It is not my purpose to claim that enhancement and preventive care never overlap. Instead, I would like to point out that human enhancement has been given too much emphasis in the discussion about considerable life extension. Even if the two issues are related, there is no logical connection between them.

Harris, for example, considers considerable life extension to be an enhancement. However, instead of following Harris's view that many preventive measures can be defined as enhancement, we can formulate the matter the other way around, for instance, that part of enhancement is preventive care. As Harris also acknowledges, at the end of the day, all measures for considerable life extension could be defined as preventive measures or treatment. Of course, this is not a sufficient reason in itself to say that considerable life extension cannot be discussed in the realm of human enhancement. Instead, I would like to promote a more modest view, namely, that there seem to be no special reasons to include considerable life extension issues in the discussion on human enhancement. It is not clear what advantages there are to classifying considerable life extension as an enhancement as opposed to talking about preventive measures or treatments that may lead to extension of human life.

In this paper, I present criticism regarding the way that some philosophers, such as Harris and Bostrom, emphasize the relation between life extension and human enhancement. It is important to note that this does not equate to taking a stance on whether considerable life extension should be accepted, morally or politically. Both Harris and Bostrom, for example, generally take a positive stance on the moral and institutional acceptability of enhancement. This is not in any way in opposition to the claim that considerable life extension is not enhancement. It is perfectly possible to hold both the belief that life extension is desirable and that it is not enhancement.

If one follows Daniels's thinking that the treatment/enhancement distinction has normative implications, my claim would actually seem to support including considerable life extension in public healthcare and insurance policies.⁷ As mentioned earlier, it is often thought that treatments and preventive measures are more readily accepted as part of public healthcare than enhancement, even though this distinction in itself is not a sufficient reason to include or exclude services from public healthcare.

In what follows, I further examine the possibility of defining considerable life extension as part of preventive healthcare. The aim of preventive measures is not to treat illnesses but to decrease the likelihood of their onset. Preventive measures include, among other things, vaccination, health education, and consulting. Prophylaxes are currently an essential part of taking care of the elderly, and forms of considerable life extension could be seen as part of that.

Let us consider an example, imagine for a moment that in the near future, a vaccination exists that would notably reduce the signs of aging in our body. In order for the vaccination to be effective, people need to be vaccinated in good time before the onset of a disease. We are currently vaccinating children against several infectious diseases in order to protect them (as children and later as adults) against harm. Accordingly, one may consider vaccinating the adult population against aging-related diseases. It is possible that this kind of prevention would affect the process of biological aging itself, which might also lead to a notable extension in the average human lifespan.

Effective vaccines have played an important role in lengthening our lives since a decrease in the mortality of under-5s has been a major factor in increasing life expectancy. Although extending the healthy life expectancy is one of the goals of medicine, no vaccinations are particularly targeted towards that. Rather, they are meant to protect us from influenza, polio, and other diseases. Therefore, analogically, any vaccination that could slow down some of the effects or signs of aging would not necessarily be a vaccine against aging as such.

If it is the case that the aging process is affected by many separate aspects and measures, it makes it harder still to define considerable life extension as enhancement. We can make a comparison with children's vaccination programs; there is no one single measure that will guarantee a healthy life for an individual or guarantee a decrease in child mortality on a societal level. It is the combination of vaccines and other measures, such as the improvement of basic healthcare and political solutions, together that make a reduction in child mortality and an increase in life expectancy possible.

I suggest, contrary to what is often presented in the philosophical literature, that considerable life extension is not primarily a form of human enhancement. It is possible to extend human life notably by preventing aging-related diseases and the signs of aging (not just superficially), which are the major cause of death in many countries. One possible criticism of my suggestion is that the measures I have described require manipulation of the “natural” biological process of aging and are thus a form of human enhancement. It might be that some of the measures would partly affect the process of aging. If, however, this effect is only indirect – a side effect of trying to tackle aging-related diseases – there need be no connection with human enhancements.

5. Conclusion

Many philosophers regard considerable life extension to be part of the debate on human enhancement. I see no reason why this should be so, that is, there is no specific reason to make such as strong connection between enhancement and life extension, as is the case in the philosophical debate.

A common view is that enhancement, unlike treatment and preventive measures, should not be covered by the public healthcare system. If considerable life extension is regarded as a form of prevention, not enhancement, there is no reason to exclude it from public healthcare based on the distinction between enhancement and treatment. Of course, this does not imply that there may not be other reasons for excluding it from public healthcare. However, it appears that the meaning of the enhancement aspect is exaggerated in discussions related to the ethics of considerable life extension.

Current life-extending measures are aimed at treating or preventing disease. In the future, medical technology will lead to more and more efficient treatments and, most likely, a longer life. In principle, it is possible that technological developments might lead to the slowing down, and even cessation, of the effects of aging. It is possible that a vaccine could be developed to prevent all, even lethal, aging-related diseases. This vaccine would be injected into adult people to prevent such diseases. It may even be possible to extend life considerably without resorting to measures that are classified as enhancement.

The distinction between enhancement and treatment is not clear. It is often thought that plastic surgery (apart from cases where it aims to fix injuries caused by accidents or disease) is the pursuance of personal ideals and should not be covered by public healthcare. Most plastic surgeries aim to enhance personal qualities. Breast implants, nose operations, and facelifts are not rare but are often considered to be personal enhancements, even a form of vanity. However, some people may suffer for years because of feelings of insecurity, and even serious mental problems, related to self-esteem. Should society participate in the cost of plastic surgery based on such reasons?

An important question is whether the application of methods that aim to extend human life (if they are developed in the future) should be covered by the public healthcare system. If we establish that considerable life extension is a treatment, the answer is probably yes. If, on the other hand, we establish that it is an enhancement, it should not be covered by public healthcare but rather by the private sector. However, this view is oversimplified; the treatment/enhancement distinction cannot necessarily provide us with satisfactory directives even though, to some extent, it is useful.

To illustrate this problem, Daniels uses the example of two boys who suffer from disadvantages in their lives because they are short. One boy suffers from a growth hormone deficiency resulting from a brain tumor, whereas the other has normal levels of growth hormone but has inherited genes from his very short parents which have regulated his height. Externally, the conditions of the two boys are very similar. Both would prefer to be taller. Yet the first boy is allowed to receive treatment to increase his height since he has been diagnosed with a medical condition. However, the genetic tendency to stay short is not regarded as a medical condition and therefore the second boy is not entitled to receive treatment.

The boy with the genetic tendency towards shortness is as disadvantaged as the boy with a brain tumor. Both boys suffer equally from their shortness and the treatment would benefit them equally. However, it is difficult to understand why only one of them is entitled to receive growth hormone treatment. As we noted before, apart from the distinction between treatment and enhancement, there are plenty of other reasons taken into account when deciding whether some treatment should be covered by the public healthcare system – this distinction should not be the only guiding factor when making decisions.

Life extension is related to a fundamental characteristic, the capability to live. This provides a reason to consider whether considerable life extension differs from other forms of enhancement, such as enhancing physical strength or cognitive capacities, and whether it is reasonable to include it in the human enhancement discussion. Enhancement is typically considered as something “extra” whereas priority is given to treatment. However, following this thought, if a person's future is literally dependent on life extension, this could mean that if other healthcare treatments are given priority over life extension, many people might have to live a much shorter life than they would actually like or could have. This could lead to societal inequality, especially if decisions are made based on the treatment/enhancement distinction. A lack of life-extending measures in the public sector could result in these services being used by well-off people through private companies and practitioners.

The aim of this paper is not to define how much support the public healthcare system should provide regarding (hypothetical) considerable life extension measures. Instead, I would like to emphasize that if the treatment/enhancement distinction is acknowledged when defining limits of the public healthcare system, it is appropriate to consider the societal implications of our chosen view of considerable life extension.

The pursuit of a considerably long life obviously touches upon many questions that are not included in this paper. One fundamental question is why we want an extremely long life? Why do we prefer a long life to a short one in the first place? Many seem to think that a long life is simply better than a short life, at least if it is not made miserable by mental and/or physical suffering. Some philosophers have noted that the experiences of happiness, well-being, and balance can be found during a relatively short life.⁸ Although this is probably true, it is hard to avoid asking why, despite the fact that a short life can be good, would we not choose a long and good life over a short and good one. An interesting point is that if we agree that considerable life extension may well be the consequence of preventing aging-related diseases, the goal is not so much extended life, but the maximization of well-being. Therefore, life-extending measures cannot be reasonably criticized purely on the basis of being specifically motivated by a desire to extend human life beyond what is considered normal.

Even if considerable life extension, and many other forms of human enhancement, may seem like distant and futuristic visions, they should be acknowledged in national and international decision-making in order for us to be aware of possible societal implications and the risks of new technologies. Currently, the European Union (EU) is preparing the introduction of a new directive on patients' rights in cross-border healthcare. This directive enables increased mobility related to healthcare because a citizen can seek healthcare services from any EU country and apply for a reimbursement from his or her own affiliated state. In Finland, for example, the introduction of this new directive required a clear definition of which health services were covered by public funds and which were not, since this has not yet been done comprehensively in the current healthcare system. If considerable life extension measures become available in the near future, many countries will have to define whether or not they belong to the sphere of public healthcare.

Acknowledgements

I would like to thank Professor Juha Räikkä and Docent Jukka Varelius, as well as members of the audience at the UNESCO Chair in Bioethics' Ninth World Conference (Naples, Italy, 19 November 2013) for comments and critique on earlier versions of this paper. I am also grateful to the anonymous referees of this journal for their helpful comments and to Professor Seppo Vainio for his assistance regarding the scientific references.

Funding

This work was supported by the Finnish Cultural Foundation [grant number 00130757].

Notes

1. The relation between life-extending measures and public healthcare has recently been discussed by Schweda and Marckmann (2013) in Bioethics.

2. See, for example, Rattan and Singh (2009), Kenyon (2010), and Lapasset et al. (2011).

3. For de Grey's view, see, for example, De Grey and Rae (2007).

4. See http://www.who.int/healthinfo/statistics/indhale/en/. In addition, in WHO's Health Systems Performance Assessment (Murray & Evans, 2003, p. 322), HALE is defined as health-adjusted life expectancy that is a “general term for health expectancies that estimate the expectation of equivalent years of good health based on an exhaustive set of health states and weights defined in terms of health state valuations”.

5. For recent discussion on enhancement, see, for example, O'Brolcháin and Gordjin (2014).

6. For early studies, see, for example, Richardson (1976). The study in question is quite old and the claim that malnutrition affects intelligence is debatable but I will assume some kind of connection here for the sake of the argument.

7. In the US system this would mean those insured on their own or by their employers, those eligible for Medicare or Medicaid, or currently (2014) those that are eligible for subsidies through the Affordable Care Act (“Obamacare”).

8. See, for example, Häyry (2011).

9. See, for example, Bostrom (2005), Bostrom and Roache (2008), and Harris (2007).