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Playing God

Genetic science has opened a moral and political Pandora's box. Should insurance companies have access to genetic information? Is widespread revulsion at the prospect of human cloning justified, or must our values adapt to the new boundaries between chance and choice?

By Ronald Dworkin   May 1999

No other chapter of our science, including cosmology, has been more exciting in recent decades than genetics. And none has been remotely as portentous for the kinds of lives our descendants will lead. Some of the moral and political problems which the new technology presents are in the future. If it becomes possible to clone human beings, for example, or radically to alter the chromosomes of an early foetus to make a child more intelligent or less aggressive, then people will have to decide whether these interventions should be forbidden or not. But many of the problems are already upon us. Tests, for example, can identify genetic predictors of disease or of predisposition to disease. So we already face difficult questions about how far and when these tests should be allowed, or required, or forbidden; and how far employers and insurance companies should be allowed to ask for the results.

Critics of genetic testing have cited various kinds of harm which might result from dissemination of its results. If it is widely known that someone will die young, or is vulnerable to a particular disease, others will treat that person differently. They may regard marriage, and even friendship with such a person, as less attractive. In some cases, people might be unemployable or uninsurable in consequence of what others know about their genes. Is this fair?

We should begin by recognising that the unfairness, if any, is already part of our lives. People who are visibly disabled suffer social and emotional harm as a result, and employers and insurance companies already have a right to ask for information about (and act on) an individual’s medical history. Nevertheless, access to a comprehensive genetic profile, or even selective information about genetic disposition to cancer, heart disease or aggressive behaviour would increase many people’s vulnerability to discrimination.

Many people’s instinctive response to the danger is to suppose that the dissemination of genetic information must be under the sole control of its subject. But this seems too strong, even in principle, and extremely difficult, if not impossible, to secure in practice. Should DNA evidence never be used in criminal investigation and prosecution? The deplorable OJ Simpson case at least educated the public in both the power and the vulnerability of such evidence. But I would be reluctant to forego its use entirely. What about occupations in which a propensity to disease poses a genuine threat to the public: a disposition to heart attack in a pilot, for example? And is it right that people who pose very different risks to insurers should pay the same premiums for their insurance? Doesn’t this mean that some are subsidising others? We think it right that smokers should pay higher rates for life insurance. Suppose we find a set of alleles which dispose someone to nicotine addiction. Would we still be unjustified in continuing to ask smokers to pay higher rates?

How can we discriminate between proper and improper use of genetic information? Suppose that insurance companies are forbidden from either requiring genetic tests as a condition of insurance, or from asking whether candidates have had such tests. Then the companies will be destroyed by “adverse selection”: people who had been genetically tested would insure heavily if most at risk, not at all if less at risk—and insurance company bankruptcies would follow. But suppose that insurance companies are entitled to ask for information from candidates seeking insurance who have had their own tests. Then people would be discouraged from having such tests, and their own and the public health will suffer. This might be called the “insurance dilemma.”

These issues display, in a more dramatic form, questions of social justice which have long been with us. In the genetic context, we need to attack the problems on two fronts. First, we must continue to develop standards of fair employment practice, administered by competent agencies, which adjudicate between public and commercial interests. Airlines should be entitled to demand appropriate tests for pilots, because the balance of public interest falls in favour of such tests. But, although no business would be wise to hire and train someone who will die of Huntington’s disease in early middle age, we should prevent most employers from asking for information which would reveal this: the impact of permanent unemployment on the short life of someone already doomed is too great not to require employers to continue to run the kinds of risk they have always run.

Second, the insurance dilemma provides a conclusive argument for why basic health and life insurance should no longer be left in the private sector. The US is alone among prosperous democracies in not having yet learned that lesson for health insurance. (Life insurance remains private in most countries.) As the insurance dilemma is likely to deepen as more genetic information is acquired, genetic research may have the unanticipated but welcome effect of striking a more general blow for justice in the US. Basic health insurance must be provided for everyone, and it must be financed out of taxation, computed by modelling a hypothetical insurance market in which insurance is offered to everyone at “community rating,” that is, at prices which assume that each candidate presented the average risk. Genetic information should be used in calculating community rates, but should not be used to discriminate between people. But private insurers should be permitted to offer extra health or life insurance, at market rates, beyond the basic package. And insurers should be entitled to demand genetic tests in setting differential rates for such additional insurance.

Assuming that basic health insurance is provided for everyone, a further question arises: how far should such an insurance system not only provide standard treatment for diseases whose risk can be anticipated by genetic testing, but also provide the new—expensive—diagnostic techniques which genetic research will make available? Genetic medicine now allows doctors to decide how a cancer patient’s genes interact with other parts of his genetic profile, in order more efficiently to design and direct chemotherapy. Techniques are being developed for altering a patient’s protein chemistry by introducing cells taken from his body and then engineering them to produce an improved genetic profile. Should these techniques be made available to everyone? Many would say: whatever saves lives must be made available to everyone, as soon as possible; it is disgraceful when lives are lost because the community is unwilling to spend the money to save them.

But a community which actually tried to live up to that “rescue principle” would have nothing left to spend on education, job training or culture; it might end up merely enabling some citizens to live rather longer in misery. If we accept that sad fact, and deny some care which would extend lives, on the grounds that it would be too expensive, should those who can afford the expensive treatment be allowed to buy it?

These are old problems, given a new twist by genetic medicine. As an attempt at an answer, consider this thought experiment. Suppose that the citizens of a society, with their present tastes and ambitions, each had the average wealth now found in that society, and that each had full, state-of-the-art information about what benefits genetic engineering might bring them, and what the cost would be of insuring to provide it. If we think that citizens generally would purchase insurance to provide a particular kind of therapy—say, genetic tests to improve the effectiveness of chemotherapy, should they need it—then a national health service should provide the treatment. If, on the contrary, we think that citizens would not purchase insurance providing for a particular therapy—say, growth treatment for a rather short child—then a national health service should not provide it. But rich people should be allowed to purchase therapy, at market rates, beyond what that calculation would mean providing for everyone. We do not in general seek equality by levelling down. Even a diminished demand for a particular therapy will stimulate research, with possibly unanticipated general benefits.

the most arresting of the possibilities which geneticists are now exploring would give doctors the power to choose which human beings will be born. People gained that power long ago, in a clumsy way, when they understood that allowing certain people, rather than others, to mate, would have consequences for the kind of children they produced. Eugenics, which was supported by George Bernard Shaw as well as by Adolf Hitler, was modelled on that simple insight. But genetic science now holds out the possibility of creating particular human beings who have been designed according to a detailed blueprint, or of changing existing human beings, either as foetuses or later, to create people with chosen genetic properties.

When scientists in Scotland cloned an adult sheep, and other scientists and publicists speculated that the technique could be used to clone human beings, committees hurriedly appointed by governments and international bodies immediately denounced the idea. President Clinton ruled that federal funds could not be used to finance research into human cloning, and the US Senate is on the verge of forbidding, through preposterously over-broad legislation, all such research. The European parliament declared that human cloning “whether on an experimental basis, in the context of fertility treatments, preimplantation diagnosis, for tissue transplantation, or for any other purpose, is unethical, morally repugnant, contrary to respect for the person, and a grave violation of fundamental human rights which cannot under any circumstances be justified or accepted.” The possibility of comprehensive genetic engineering—altering a zygote’s genetic inheritance to produce a battery of desired physical, mental and emotional propensities in the way contemplated by the recent film, Gattaca—has also aroused great fear and revulsion.

How can we justify, or even explain, this blunderbuss reaction to cloning and comprehensive genetic engineering? Three kinds of objections are often mentioned. First, there are potential physical dangers. We do not know whether attempted engineering would result in an unacceptable number of miscarriages, or in the birth of an unacceptable number of deformed children. Second, resistance to engineering is sometimes grounded in worries about social justice. Cloning, if available, is bound to be hideously expensive for a long time; hence it would be available only to rich people who may want to clone themselves out of vanity, increasing the unfair advantages of wealth. (Those horrified by the prospect of cloning have cited the spectre of thousands of Rupert Murdochs or, even worse, Donald Trumps.) Third, the reaction might be explained by an aesthetic value. Engineering, if available, might well be used to perpetuate presently desired traits of height, intelligence, colour and personality, and the world would be robbed of the variety which is essential to novelty, originality and fascination.

In my view, these objections do not separately or together justify the strength of the reaction I have described. Take the question of physical safety. There is little reason to think that either cloning or engineering would produce germ line damage threatening generations of deformity. In any case, these dangers are not enough, on their own, to justify forbidding the further research which could refine our appreciation of any genuine threats. Regulation can rein in the cloning cowboys, who are bound to appear, without closing down research altogether. But if we are assessing the risks of damage which experimentation or testing might produce, we must also take into account the hope that advancing and refining the techniques of genetic engineering will hugely decrease the number of defects and deformities with which people are now born, or into which they grow. The balance of risk may well be thought to tilt in favour of experimentation.

What about the question of justice? We can easily imagine genetic engineering becoming a perquisite of the rich. But these techniques have uses beyond vanity. Parents of a desperately sick child might want another child, whom they would love as much as any other, but whose blood or marrow might also save the life of the sick child from which it was cloned. Cloning individual human cells, rather than an entire organism, might have even more evident benefits. For example, a re-engineered and then heavily cloned cell taken from a cancer patient might prove to be a cure for that cancer when the clones were reintroduced. We must also count benefits beyond the narrowly medical. Childless couples, or single women or men might wish to procreate through cloning, which they might think better than the alternatives available. Or they may have no alternative. The remedy for injustice is redistribution, not denying benefits to some with no corresponding gain to others.

And what about the final aesthetic objection? We already have clones-genetically identical multiple births are clones-and twins and other genetically identical children show that identical genes do not produce identical phenotypes. We may have underestimated nature in the past, but nurture remains important, too, and the reaction to genetic engineering has underestimated its importance, in turn. Nevertheless, people do fear that if we replace the genetic “lottery” with engineered reproduction, the welcome diversity of human types will be progressively replaced with uniformity dictated by vogue. To some degree, greater uniformity is unambiguously desirable: there is no value, aesthetic or otherwise, in the fact that some people are doomed to a disfigured and short life. And it is not clear how far engineering, even if it were freely and inexpensively available, would actually threaten desirable diversity. Presumably all parents, if given a choice, would wish their children to have the level of intelligence and other skills we now regard as normal. But we cannot regard this as undesirable: it is, after all, the object of education, ordinary as well as remedial, to improve intelligence and skill levels across the board.

Do we have good reason to fear that if parents had the choice between sexual reproduction and cloning, they might often choose the latter? This seems unlikely. Do we have reason to fear that parents will engineer a reproductive zygote in order to make it a male rather than a female child? It is true that in certain communities in northern India, for example, male children are preferred to female. But that preference seems so sensitive to economic circumstances and shifting cultural prejudices that it offers no grounds for supposing that we will suddenly be swamped, around the world, with a generation dominated by males. Selective abortion for sex has been available, as a result of amniocentesis and liberal abortion laws, for some time now, and no such trend seems to have been established.

The fear, however, goes beyond a fear of sexual asymmetry: it is a fear that one phenotype—say, the blond, conventionally good-looking, non-aggressive, tall, musically talented and witty—will come to dominate a culture in which that phenotype is particularly valued. We should pause to notice the scientific assumptions embedded in that fear: it supposes not only that comprehensive genetic design is possible, but that the various properties of the preferred phenotype can be assembled in the same person through that design. This is improbable. It seems much more likely that even parents with state-of-the-art engineering at their disposal would have choices to make—and risks to run about the impact of nurture and experience—and that they would make these choices differently in response to the very differences among them which we now celebrate. The subsequent impact of differing personal choices by offspring, in search of individuality, would enlarge on those differences.

Most people delight in the mysteries of reproduction. Many, perhaps most people would forego engineering, beyond trying to eliminate obvious defects and handicaps. If this is right, the aesthetic objection is overblown and at best premature. We would need much more information, of a kind which could only be produced through research and experimentation, before we could even judge the assumptions on which the objection is founded. It would thus seem irrational to rely on that objection to prevent further research.

These arguments and objections do not seem to provide what TS Eliot called an “objective correlative” for the revulsion I describe. People feel a deeper, less articulate reason for that revulsion, even if they cannot express it, or express it only in logically inappropriate language—like the bizarre reference to “fundamental human rights” in the European parliament resolution. But what seems to underlie much of the hostility is the objection to “playing God.”

Playing God is thought to be wrong in itself, quite apart from any bad consequences it will have or may have for any identifiable human being. But it is unclear what the injunction really means—unclear what playing God is, and what exactly is wrong with it. It can’t mean that it is always wrong for human beings to attempt to resist natural catastrophes, or to improve upon the hand which nature has dealt them. People do that—have always done that—all the time. What is the difference, after all, between inventing penicillin and using engineered and cloned genes to cure even more terrifying diseases than penicillin cures? What is the difference between setting your child strenuous exercises to reduce his weight or increase his strength, and altering his genes, while still an embryo, with the same end in view?

We must try to answer these questions, but we must begin at some distance from them, in the overall structure of our moral experience. That structure depends on a fundamental distinction between what we are responsible for doing or deciding, individually or collectively, and what is given to us as a background against which we act or decide, but which we are powerless to change. For the Greeks, this was a distinction between themselves and their fate or destiny, which was in the lap of the gods. Even today, for people who are religious in a conventional way, it is a distinction between how God designed the world, including our natural condition in it, and the scope of the free will he also created. More sophisticated people use the language of science to the same effect: for them the basic distinction is between what nature, including evolution, has created, by way of particles, energy and genes, and what we do with those genes in the world. For everyone, the distinction draws a line between what we are—for which either a divine will or a blind process is responsible-and what we do with that inheritance, for which we are responsible.

This crucial boundary between chance and choice is the spine of our morality, and any serious shift in that boundary is seriously dislocating. Our sense of a life well-lived, for example, is shaped by supposed givens about the upper limits of human life span. If people suddenly lived ten times as long as we now live, we would have to change our opinions about what counts as an attractive life, as well as our opinions about what activities which carry the risk of accidental death for others, such as driving, are morally permissible. History already offers examples of how scientific change dislocates values. People’s convictions about the responsibilities of leaders to protect their own soldiers in war, at any cost, changed when scientists split the atom; and hugely increased the carnage which those convictions could justify. People’s convictions about euthanasia changed when death-bed medicine dramatically increased a doctor’s power to extend life beyond the point where that life had any meaning for the patient. In each case a period of moral stability was replaced by moral insecurity, and it is revealing that in both episodes people reached for the phrase, “playing God.”

Genetic science has made us aware of the possibility of a similar, though far greater, pending moral dislocation. We dread the prospect of people designing other people because that possibility in itself shifts the chance/choice boundary which underpins our values. Our physical being—the brain and body which give each of us our material substrate—has long been the absolute paradigm of what is both devastatingly important to us and beyond our power to alter, either individually or collectively. The popularity of the phrase “genetic lottery” itself shows the centrality of our conviction that what we most basically are is a matter of chance, not choice.

If we were to take seriously the possibility we are now exploring—that scientists really have gained the capacity to create a human being with any phenotype that they or prospective parents choose—then we could chart the destruction of settled moral attitudes, starting at almost any point. We use the chance/choice distinction not simply in our assignments of responsibility for situations or events, but in our assessments of pride, including pride in what nature has given us. It is a striking phenomenon that people take pride in physical attributes or skills they did not choose or create, such as physical appearance or strength, but not when these can be seen to be the results of the efforts of others in which they played no part. A woman who puts herself in the hands of a cosmetic surgeon may rejoice in the result, but can take no pride in it; certainly not the pride she would have taken if she had been born into the same beauty. What would happen to pride in our physical attributes, or even what we make of them, if these were the inexorable results not of a nature in whose pride we are allowed, as it were, to share, but of the decision made by our parents and their hired geneticists?

Further, we accept the condition in which we were born as a parameter of our responsibility, but not as itself a potential arena of blame (except in those cases, of relatively recent discovery, in which someone’s behaviour altered our embryonic development-through smoking, for example, or drugs). Otherwise, although we may curse fate for how we are, as Richard Crookback did, we may blame no one else. The same distinction holds for social responsibility, too. We feel a greater responsibility to compensate victims of industrial accidents, and of racial prejudice, than we feel a responsibility to compensate those born with genetic defects or those injured by lightning, or in those other ways which lawyers and insurance companies call, in an illuminating phrase, “acts of God.” How would this change if we are as we are through the conscious decisions of others? The terror many of us feel at the thought of genetic engineering is not a fear of what is wrong; it is a fear of losing our grip on what is wrong. We worry that our settled convictions will be undermined, that we will be in a kind of moral free fall, that we will have to think again against a new background, and with uncertain results. Playing God is playing with fire.

Suppose that this hypothesis is correct, and that it accounts for the powerful surge in people’s emotional reaction to genetic engineering. Have we then discovered not only an explanation but a justification for the revulsion? No. We would have discovered a challenge we must take up, rather than a reason for turning back. Our hypothesis reveals only reasons why our contemporary values may be wrong or ill-considered. If we are to be morally responsible, there can be no turning back once we find, as we have found, that some of the most basic presuppositions of these values are mistaken. Playing God is indeed playing with fire. But that is what we mortals have done ever since Prometheus, the patron saint of dangerous discovery. We play with fire and accept the consequences, because the alternative is an irresponsible cowardice in the face of the unknown.

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