Third Category Prevention

We do as yet not have a clear understanding of what can plausibly count as treatment and what cannot. That poses problems of a primarily conceptual nature and highlights several other semantic fields whose boundaries are also not very clearly defined, such as those of "health" and "disease". But even before approaching these questions, one encounters another problem with a clear-cut distinction in the dualistic scheme of treatment and enhancement: It does not seem to do justice to strategies of prevention. Vaccination provides us with a particularly clear example of preventive medicine, but practices of prescribing and taking statins to reduce the likelihood of stroke and myocardial infarction, and other such preventive strategies could be cited as well. Nobody doubts that vaccination, and similar preventive measures of the said kind, are a sensible and legitimate part of medicine and medical research. On the other hand, they cannot properly be labeled "treatments", not even "anticipated treatments". Rather, they are something directed against treatment, viz. designed specifically to avoid its future necessity. Considered just in themselves, they amount to a strengthening of the human organism and therefore a certain type of enhancement.

One could certainly settle this conceptual difficulty by simply introducing prevention as a third category besides those of treatment and enhancement, and then just include it into the legitimate sphere of medical practice by relying on a self-evident intuition. Disease-related prevention is an integral element not only of the practical reality of modern medicine, but also of its moral image.169 As part of proper medicine in this sense, prevention is connected to treatment insofar as it functions as a

169 We use the term "disease-related prevention" to hint at the fact that there are other forms of prevention of unwanted states of affairs which could also possibly employ new techniques of intervening in the psyche. What we mean here are forms of prevention that could be called "sociopathy-related", destined, for instance, to prevent someone from developing a disposition to criminal behaviour. From a normative point of view, these latter forms are, in general, a lot more problematic than the former. Presently, we use "prevention" only in its disease-related sense. However, we will deal with problems of sociopathy-related preventions when we tackle the questions of treating or enhancing mental states of prison detainees.

way of anticipating and circumventing the otherwise impending necessity of the latter. In a normative perspective, i.e. considering questions of legitimacy, this is perfectly plausible. Both concepts, treatment as well as prevention, are related to, or oriented towards, "fighting off" or controlling diseases, i.e. states of physical or mental well-being below a certain standard judged as "healthy" by the relevant criteria within a given society (regardless of what these relevant criteria are and how they are being derived.)170 The term "fighting" is metaphorically indicative of the common normative ground of both concepts: The task of both treatment and prevention is to confront disease by preventing, removing, reducing, or at least confining and controlling it.171

The crucial point is that, from a normative perspective, "prevention" bears a close affinity to, or in some sense may even be coterminous with, the concept of treatment. On the other hand, from a descriptive or phenomeno-logical perspective, some forms of prevention, such as vaccination or taking statins, are a specific form of enhancement, aiming at enhanced immunity from disease. To be sure, not all preventive medicine is enhancement. Perhaps only a small part of it is.172 But even this small part is sufficient to blur the lines between what is "proper medicine" and what is not, which had offered itself as a normative corollary of the distinction between treatment and enhancement. For even if vaccination against major diseases results in a super-normal strength of human immune systems, it remains a perfectly sensible medical measure and should therefore be considered a legitimate part of proper medicine (Juengst 1998). This casts a first doubt on the widespread contention that this distinction, holds decisive normative force and is, therefore, able to inform us about what forms of intervention are ethically permissible, or even obligatory, (treatment) and those which are not (enhancement). This is quite obviously a crude simplification, with respect to both the purely descriptive demarcation and the normative guidance it is supposedly able to provide.

To complicate the picture, one might even add a fourth category: physical or psychic interventions that cannot be considered treatment, prevention or enhancement, but which do, nevertheless, have a close connection to the sphere of medicine. Their relation to medicine is threefold. First, they can be adequately performed only by trained physicians. Second, there is a strong societal demand for them as services to be provided for by

170 For our present purposes, "disease" is meant to encompass any pathological state, including disability. There are, of course, differences between disease and disability and some of them certainly bear normative weight, though not for the distinctions we are trying to establish here. For disability, no less than disease, is subject to legitimate treatment within the sphere of proper medicine.

171 This, of course, points to familiar problems in the long-standing debate about the concept of disease. We will touch these problems in the following section (sub 6.3.3).

172 For instance, preventive screenings for late-onset diseases are certainly not.

physicians. Third, their individual refusal may lead to a considerable amount of suffering, or conversely, their provision to relief from considerable burdens. Abortion would be an example of such a procedure. Norma-tively speaking, it is probably closer to enhancement (even though lexically it hardly belongs to the scope of meaning of this concept). Far from being a disease in need of treatment, pregnancy is, in fact, proof that a woman is in good physical condition. Still one may doubt this by saying that - at least from the subjective point of view of the pregnant woman - an unwanted pregnancy puts her in a potentially "harmful" physical state, even though some might consider this a rather strange aberration from the common meaning of "harm".173 Abortion aside, it is not easy to think of any other example of a procedure that would fit this final category, except perhaps the related, but largely harmless, medical practice of prescribing female contraceptives.174 So it seems that we can, without a major risk of missing important insights, neglect this final category in the context of our analysis.

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