Schedule

Brain-based technologies increasingly facilitate greater understanding of brain activity, and its instrumentalisation across a variety of domains. This includes in therapeutic applications, for enhancement purposes, and for recreational pursuits. Central in all of this is brain data -- the processed outputs from brain signal recordings of many types. Understood via data, the brain appears more legible than it has in the past. And through understanding brain data dynamics, control of brain activity seems ever more plausible. While there are undoubted agency-boosting benefits to be derived from neurotechnology development, questions remain. How ought we to account for the potential in datafied brains to shape and be shaped by us?

The emphasis upon data and its processing offers a novel guise for an established mode of scientific endeavour in empiricism. Data appears to offer an objective dimension of brain activity, and thereby of cognition and behaviour in general. These data can be revealed by scientific methods centred on analysis of the active brain. Given the role of algorithms, moreover, in being able to detect patterns indiscernible to the human scientist, datafication seems to turbo charge empiricism. The role for theory is apparently diminished through using data science techniques — patterns that appear in troves of data are objectively discerned by algorithmic processing whether they are being sought out or not. In other words, by letting algorithms loose on troves of data we can discover patterns we didn’t know it was worth looking for. From those patterns we can derive objective knowledge we didn’t know we didn’t know. Some have termed this the ‘end of theory’⁠ and it has found advocates who would see data as ushering in a new era of discovery-led scientific research.⁠

Using data to gain greater understanding of how the mechanisms underlying brain state dynamics work, these dynamics could increasingly become the object of research themselves. Therapeutically, applications in this arena could target psychiatric problems. In terms of human enhancement too there could be applications with differing levels of ethical concern – enhancing a surgeon’s wakefulness for long surgeries, for instance, versus that of combat soldiers, or bomber pilots, to optimise battlefield readiness. These instrumental interventions demand scrutiny in terms of what values are at work, and a variety of other dimensions. These provide the basis for an array of novel ethics considerations, based in the datafication of brains.

Perhaps especially with respect to whole-brain computer modelling approaches to the brain, the idea of data dashboarding can be seen to arise. It is a small step to take, to see brain data as reporting brain states to being adjustable parameters for brain states. If we have a dashboard that offers the chance for dynamic intervention upon our own brain states, reified through recorded data, how should we understand the use of that dashboard? The datafication of how we understand the brain, coupled with the potential for whole-brain computational modelling opens the possibility for re-imaging the brain as a means for taking control of our cognition and behavioural dispositions and with that, ourselves. We don’t need to decide whether the prospect of such literal self-control is good or bad. But the very idea requires conceptual and ethical scrutiny – we need to know what it means.

Neurotechnologies promise cognitive and motor rehabilitation and also the possibility of reading and writing neuronal activity. But should we? In this talk, I would like to present some of the risks and challenges posed by neurotechnology. The possibility of accessing the internal processes of the brain by measuring, stimulating and/or modifying its neural activity raises multiple ethical questions: Can neurotechnology change your behaviour, self and autonomy? Can neurotechnology eliminate the most intimate privacy by reading our "thoughts"? And with the combination of machine learning techniques (Artificial Intelligence) and neurotechnologies, some of the questions are: Is it possible to decode neural signals better or this means amplifying and obtaining a signal that does not correspond to cognitive intentions (unintended information)? The development of neurotechnologies together with artificial intelligence has a great impact in clinical contexts but also beyond clinical realm. There is a growing use of neurotechnology in military contexts, the entertainment industry, marketing and even the do-it-yourself movement. This raises important philosophical questions such as the ethical, legal and economic impact of neurotechnology. The issue of human-machine interaction requires an interdisciplinary approach and the involvement of multiple stakeholders.

The outline of my talk are five points. In the first two points, I will explain the basic characteristics of the science (neuroscience) and technology (AI) behind neurotechnologies. In a third point, I will briefly discuss some of the ethical issues that emerge from the use of neurotechnologies. For instance, what impact neurotechnology will have on issues such as agency, autonomy, privacy, responsibility etc. In particular, I will explore what ethical principles are affected by the current development of neurotechnology and how to guarantee the safety and well-being of users of this type of technology, which can radically transform our embodiness, influence our perception of ourselves and also alleviate clinical pathologies. Of particular interest, is to focus on AI driven approaches to current neurotechnologies. How different algorithms process brain signals? Are they altering the signal itself in some ways, leading to unintended information? How the application of certain AI techniques or algorithms in the manipulation of brain signals changes our idea of information and more importantly information about the self or self-knowledge?

Another point I will discuss is the future of rehabilitation with novel methodologies such as Virtual Reality (VR) for motor rehabilitation. In this point, I just want to speculate what new methodologies we have at our disposal to achieve the goal of rehabilitation. Finally, I will discuss some lessons learned during the period of the EXTEND project as a member of the research group in charge of analysing the ethical, legal and social implications of the EXTEND technology. In this last point, I do not want to talk about the ethical aspects of the EXTEND technology but rather give a first-person perspective of the project activities and what I have learned. I have no doubt that ethics in responsible research has a central role to play because it allows us to analyse the possible harms and thus create the best innovation for everyone.

In this presentation I will reflect on the possible impact of some brain-affecting technologies for identity and authenticity. I will briefly analyse Deep Brain Stimulation (DBS), an invasive neurosurgical procedure and Brain-machine interfaces (BMI), a group of technologies designed to connect the brain to external devices. Both technologies affect the brain directly, are used to treat or ameliorate disorders such as Parkinson’s disease, and raise somewhat similar ethical problems. I will ask whether these brain-affecting technologies could lead to morally relevant changes in the identity or authenticity of the treated persons. The questions that will guide this intervention are: Can technologies of this type radically change a person? Could they cause someone to cease to be him or herself?

Personal identity is generally considered an important aspect of ethics. Who I am is directly related with my values and purposes. The concept of personal identity -the idea that each of us is a unique being, different to the rest, and whose existence extends over time- is essential for understanding our moral world. Personal identity’s functionallity also distinguishes it from personality, which tend to be confused.

Authenticity, as personal identity, is also a relevant ethical concept, although arguably trickier and less discussed than personal identity. A first and tentative definition could be that being authentic is the same as being “true to oneself”, that is, to live in accordance with one’s «true self». This very basic definition varies from one philosopher to another, but the main idea of ethical truthfulness is the common attribute to all forms of authenticity. In the last decades, some authors have even begun talking of an “ethic of authenticity”. The growing literature on human enhancement has reinforced this focus on authenticity. Some authors have argued that enhancement could affect us in such a way that we would become inauthentic. These are valid concerns, but ultimately I believe they miss the point because they operate under an exceedingly strict concept of authenticity. I see two main problems with these positions: 1 They fail to take into account the dynamic nature of our personal identity; and 2 They rely on an unrealistic notion of truthfulness.

The question I want to ask is: can technologies such as DBS or BMI be a threat to our personal identity or to our authenticity?

I would say that personal identity is not really threatened by these technologies. Of course, this depends on what definition and understanding of personal identity we hold. A static view of personal identity could affirm that DBS or even BMI can change the personal identity of someone. If a timid, introvert and depressive person becomes a joyful extrovert under the influence of these brain-affecting technologies, one could think we are in front of a different person. We sometimes talk in these terms when we see a radical personality change. But our moral and legal practices show otherwise. A dynamic understanding of personal identity, which allows changes to happen to someone without changing their personal identity, seems closer to our real and daily understanding. Not embracing this dynamic view of personal identity would force us to consider virtually all changes in our life as possibly identity changing. Not only brain-affecting technologies, but also events such as our wedding, becoming a parent, losing a relative and many more could be considered to be identity-changing. But this seems counter-intuitive and implausible.

Authenticity, on the other hand, is a more difficult subject to tackle. Even though we are used to operate under some notion of truthfulness -when, for example, we say that someone is “acting fake” when they don´t behave as expected- a closer examination of this idea shows this concept is much more vague than what we could have thought, given how extended its use is. Charles Taylor relational view of authenticity could show, in line with some psychological findings, how the idea of “true self” is connected not so much to some sort of inner and true self, but to some features that we tend to understand as intrinsically valuable. Particularly, people tend to be considered more authentic when they are more extroverted, altruistic, and overall sociable.

If we embrace this understanding of authenticity, it is clear that brain-affecting technologies such as DBS and BMI can be a threat to authenticity. If a technology turns someone anti-social or depressive, we could say her authenticity has been damaged or disrupted, and could conclude that “she is no longer herself” or that “she is not really that way, that is not her true self”.

However, even if we accept this conclusion, we might ask: is this enough to recommend against the use of DBS or BMI? What would be better, a person who basically cannot live because of its tremors and general physical problems, or a person who can physically live but is “inauthentic”? I would say that this kind of dilemmas require a case by case examination. However, I would not give authenticity such a high value that it overrides all other considerations, as the «authenticity rhetoric» sometimes tends to do. In fact, there are already cases of persons facing this very dilemma who have elected to keep using brain-affecting technologies to gain physical functionality even when that brings severe personality changes and undermines their authenticity.

In his article Ephemeroi – Human Vulnerability, Transhumanism, and the Meaning of Life (2019), Michael Hauskeller argues that transhumanism is ultimately a quest for human invulnerability, and that vulnerability is what makes us human. That is, the value of human vulnerability would challenge the legitimacy of the transhumanist project. He is not the only author that has claimed that the transhumanist project will take something away from us – something we deeply value and makes us what we are: our vulnerability (Asla 2019, Cannavò 2019, Llano 2019, Woollard 2019).

We agree that any futuristic project regarding the human species needs to acknowledge the importance of vulnerability in the human condition. However, we do not agree that there is a fundamental incompatibility between this acknowledgment and the transhumanism per se. Our argument develops in two steps: first, we clarify the idea of vulnerability and we propose a version compatible with the pursuit of well-being through technology. Then, we distinguish a strong and a weak version of transhumanism, and we analyze the role of vulnerability in each of them. We conclude that there is a possibility for tempered, vulnerability-friendly transhumanism.

On the one hand, vulnerability can refer to the existential condition of frail and mortal human beings. This idea recalls on the interdependence that links us between ourselves and the need for care omnipresent in all life stages, in different degrees (Butler 2004, Fineman 2004 and 2008, Delgado Rodríguez 2017). On the other hand, social vulnerability focus on the different situations of fragility and peril that people can face depending on the inequalities and oppressions, such as gender or functional diversity (Luna 2009). We propose an idea of vulnerability that both recognizes the universal interdependence and fragility of human beings and understands how social structures impact the situation of each individual.

Furthermore, vulnerability can be understood not only as a limitation but also as a creative category. We are all vulnerable, hence we need (a) to associate with others in order to sustain a valuable life, and (b) collectively modify our environment in order to adapt it to us. Our creative capability comes from our fundamental inadaptation to the world (Nussbaum 1986). We change the world to reduce our vulnerability. Admittedly, we can never beat imperfection: as Coeckelbergh argues, we change our current vulnerabilities transforming them into other ones (Coeckelbergh 2013). A non-essentialist account of vulnerability needs to consider that we do work for reducing harm and peril and that this is a valuable, long-lasting aim in human history. Transhumanism needs to be conscious of human vulnerability, and it should avoid any fantasy of omnipotence or total independence. However, this does not mean renouncing either the project of diminishing harm and peril through technology, or enhancing the capabilities of healthy people.

Regarding the transhumanist project, we distinguish here a strong and a weak version. The strong version of transhumanism proposes a view of the posthuman that would certainly be less bodily vulnerable than actual human beings. However, many authors have noted that there are considerable risks of new social vulnerabilities, due to the new inequalities and power relations that can be created by radical inequalities of the posthuman future (Harris 1992, Silver 1997, Fukuyama 2002, Annas et al. 2002). The weak version of transhumanism can be more vulnerability-friendly. For that, it is important that any futuristic project takes into account (i) the value of caring relationships and (ii) the interdependence and the importance of social structure in managing vulnerability.

In conclusion, we defend that there is a possibility of a transhumanism conscious of human vulnerability, capable of both challenging harm through technology and valuing the role of vulnerability in human life, particularly the moral value of caring relationships. Transhumanism needs to leave aside all images of the future that neglect vulnerability. By human enhancement, we would probably change some of the current vulnerabilities, but new ones would come up. The posthuman will certainly be vulnerable in new, even unpredicted ways. The debate should focus on this crossroads: what vulnerabilities are we going to tackle first using human enhancement technologies, what novel vulnerabilities can arise from these changes, and what scenarios are worth pursuing for us as a species.

EXTEND aims at developing the novel concept of Bidirectional Hyper-Connected Neural Systems (BHNS) to extend the capabilities of neural interfaces with minimally invasive communication links between multiple nerves in the body and multiple external devices. BHNS will be done by developing wireless neuromuscular (injectable) interface technology that enables distributed stimulation, sensing, processing and analysis of neuromuscular activity. This dense network of interconnected microimplants will be controlled by eTextile garments to improve the portability of the system. EXTEND will showcase the advantages of this new technology in two applications: (1) tremor reduction in essential tremor (ET) and Parkinson’s disease (PD), and (2) neural interfaced assistive wearable robots for spinal cord injury (SCI).

The EXTEND technology and scientific development follow an incremental iterative approach in three cycles that build on one another to ease the approval by the Ethics Committees. In the first cycle, we used thin-film intramuscular electrodes with 12 electromyography (EMG) recording points and 3 stimulation points, controlled by computer. The second cycle includes all the miniaturization of the system and its wireless control. The third cycle will lead to the final EXTEND implants, fully implanted, powered by the eTextiles and communicating with other implants in real time.

We already showcased the potential of the first cycle of electrodes to reduce tremor in ET patients. ET and PD are the main movement disorders causing pathological tremor. Both disorders are estimated to affect up to 5% of the world's population. Treatment of tremor by deep brain stimulation (DBS) or medication directed at supraspinal structures and circuits is ineffective in approximately 25% of patients. Therefore, alternative approaches should be considered and developed. Our study (https://ieeexplore.ieee.org/document/9171555) proposed and clinically tested electrical stimulation below motor threshold to achieve prolonged reduction of wrist flexion/extension tremor in ET patients, using cycle 1 electrodes. Results showed acute and prolonged (24 h) tremor reduction using a minimally invasive neurostimulation technology based on electrical stimulation of primary sensory afferents of wrist muscles. This strategy might open the possibility of an alternative therapeutic approach for ET patients. We will try to replicate similar strategies using cycles 2 and 3 in ET and PD patients.

On the other hand, SCI affects the quality of life of patients because of its many possible consequences: affected bowel and bladder control, affected sexual function, affected sensory and motor function, as well as problems in walking, eating, grasping, pain and spasticity, among others. Currently, about 1,000 people in Spain suffer a traumatic SCI each year, which brings the total number of affected nationally to over 30,000. Exoskeletons used in neurorehabilitation have emerged in the last decade as a technology that allows multiple, intensive and more effective sessions of gait training, allowing SCI patients to improve their daily life performance. Intramuscular signals from multiple muscles can be used to decode the remaining muscle force in these patients and tailor the level of assistance, resulting in a more natural and comfortable operation of the exoskeletons. Therefore, one of the goals of the project is to test the use of the different electrodes developed in each different cycle to enhance intuitive control of exoskeletons used to rehabilitate motor function. During the talk, you will see our preliminary results.

EXTEND consortium brings together nine (9) partners from five different countries (Germany, Iceland, Spain, United Kingdom and USA) on the basis of the multidisciplinary expertise and trans-nationality required for meeting its ambitious objectives and ensuring proper exploitation of results, mostly technologically and scientifically, but with an innovation perspective.

Medicine is a discipline permeable to change. Technological advances and novel social demands can transform what we conventionally understand as a legitimate medical practice. Medicine now accommodates a wide range of practices that are not strictly related to the treatment of disease. For instance, medical professionals admit among their tasks the improvement of immune functioning in healthy people through the administration of vaccines, or helping people to have (or avoid having) descendants, or serving some individuals to feel more pleased with their own physical appearance through, for example, a hair transplant.

The increasing possibility of enhancing the capabilities of healthy people through biomedical innovations leads to a very interesting debate. The question is whether the inclusion of enhancement within the purposes of medicine can be justified. There have been two traditions that have taken a clear position on this issue: naturalism and welfarism. In this talk, we argue that both theoretical stances have considerable shortcomings in addressing this controversy and we suggest that the capability approach is a more convincing alternative to them. In addition, we think the biomedical enhancement of the capabilities related to procedural autonomy can be a desirable way of making people freer through medicine.

On the one hand, naturalism defends that medicine should be concerned about restoring normal functioning in a biostatistical sense. Consequently, human enhancement goes beyond the proper goals of medicine (Fukuyama 2002; Kass 2003; Sandel 2007). We think that this conception has at least two problems. Firstly, it endorses the treatment-enhancement distinction—a dividing line that we think is often descriptively unclear and overall normatively irrelevant. Secondly, naturalism sometimes relies on an essentialist vision of medicine as related only to the therapeutic endeavour. This conception is inaccurate and even Boorse (2016) said that medicine has historically not only been restricted to treatment and it does not need to be recalcitrant to enhancement in the future.

On the other hand, welfarism advocates for improving the well-being of humans through medical practices. This normative conception has been defended by some of the champions of enhancement (Savulescu 2006; Savulescu, Sandberg & Kahane 2011). Although welfarism overcomes some of the shortcomings of naturalism regarding its approach to enhancement medicine, it has its own problems. In particular, preferentism—a conspicuous view within welfarism—is based on the satisfaction of subjective well-being preferences that can be distorted by unjust expectations due to unfair systemic inequalities. Moreover, welfarism endorses enhancement as long as it mainly promotes well-being, the only thing that is intrinsically valuable according to welfarists, without giving due importance to other consequences of biomedical interventions, such as increasing freedom.

Having said that, the capability approach is a stronger candidate to include human enhancement within the goals of medicine for at least four reasons. First, it overcomes the former objections raised against naturalism and welfarism. Second, it is an open-ended theory in normative and conceptual terms that aims to foster the activities that increase the freedom to achieve well-being. Third, it is attentive not only to social and environmental differences that affect individuals, but also to the biological factors that condition human freedom and welfare. Fourth, and lastly, it is not necessarily committed to a particular distributive (egalitarian, sufficientarian, or prioritarian) rule and it makes sense that, as a matter of justice, the treatment and prevention of disabilities or health-related capability deprivations are generally of more importance than enhancement.

Finally, improving the capabilities related to procedural autonomy can be a near possibility for including enhancement within medical practice. Procedural accounts emphasize that autonomous decisions should be based on a critical and rational process of self-scrutiny about personal preferences. Procedural autonomy is based on a wide variety of capabilities—such as self-control, cognition, executive function, (working and long-term) memory, practical reasoning, gratification delay, and so on—that can be influenced and improved by biomedical means. These capabilities can be fostered by cognitive enhancement drugs, emerging neurotechnologies, and by future genetic technologies applications. If these capabilities are enhanced by biomedical means, it can be a case by which medicine makes people freer.

Perfective modifications introduce an important issue: the change in the identity of individuals. There may be no paradigm or ideal prototype to strive towards. In many cases, enhancement is not seen as a deliberate action to achieve an ideal, but rather as a one-time intervention that can lead to a change that has beneficial effects for the individual. So, progressively, modifications are introduced, the whole of which represents a certain continuous improvement. An unlimited process that can open up endless possibilities without an ultimate perfect solution.

The question that then arises is what happens to the identity of individuals who, having enhanced themselves, cease to be who they are and become "others", although with some form of continuity that could allow following a trace of permanence of the self. The improved self that claims to be "the best possible self" is not the same self as the one that decided to enhance herself, although there is some continuity between them.

In order to solve this paradox, it is pertinent to ask what is identity. Some authors have spoken of numerical identity and also of narrative identity, as different ways of approaching this continuity of the individual who changes. Numerical identity refers to the permanence of certain traits that make it possible to consider that someone is still the same person despite the fact that some changes may occur. These traits can be biological and psychological. Narrative identity, on the other hand, emphasizes the capacity to interpret the biographical story, assuming the changes and being able to integrate the modifications. The individual's conception of herself involves the elaboration of a biographical narrative in which events, experiences and changes are given meaning. The question of "who I am" requires an exercise in the construction of one's own story. Defining what shapes the life journey through what has been happening, the transformations that have taken place, the learning that has been acquired, or the image of oneself that has been generated.

The question arises as to whether a process of enhancement forces a continuous reconstruction of the identity of individuals, and what are the consequences of such a process, that is to say, what does it mean to speak of being a human being when the characteristics that define him or her are permanently and voluntarily altered. For example, in the case of neuroenhancement, it might be difficult to determine to what extent a subject's approval of her new improved personality is assuming capacities that have been modified in a process of neuroenhancement.

That is, the assumption of a new identity with new capabilities is affected by the intervention performed, which raises a question about the extent to which this decision is autonomous. The subject who decides to enhance herself may not foresee that after the process she will not be the same person and, even supposing that the first decision to improve had been a free and autonomous decision process, once it has been made, the evaluation of the result is made by a subject whose capacities are different from those of the subject who made the decision. Hence, this alteration of her identity generates the paradox that the results of the intervention cannot finally be assessed by the initial subject who chose it.

The new capacities could generate a new self, which, however, was chosen by a previous self, in an exercise of autonomy. Despite the apparent radical break of identity, this individual could tell his or her story with a before and an after. It could be thought that, then, narrative identity would be the redoubt of this continuity of meaning.

Narrative identity, which allows us to construct the story of an ever-changing self, cannot be adequately understood without the relationship with others. Who we are has a close relationship with the rest of humanity, to the point that a large part of that identity has to do with recognition, with the fact that other people recognize us and give us a name, they also construct an image of ourselves, which is part of who we are, and that they are also in our story. Even if a person loses her memories, she can recompose her identity and her biography through the story of others, of those who know her, of those who remember who she was. Identity has a relational dimension.

In the context of enhancement, this implies assuming that the relational dimension is central to one's own identity, from a perspective that is narrative and that assumes a process of continuous reconstruction.

As in many other cases, there is no consensus on a single definition of Human Enhancement and many have been offered. Some, very estimable on the other hand, and that have contributed to the debate, incorporate terms such as “well-being” (Savulescu, 2006) or “normal” (Daniels, 2000) that are far from being easily understood and that in turn require a good dose of clarification. Others are too restrictive (Giubilini and Sanyal, 2015). I am not going to add one more, but I am going to offer an operational definition that helps us to move forward. We will understand by "Human Enhancement" those modifications of human capacities, produced by recent scientific and technological advances, carried out in the human body, and that go beyond what is considered normal today.

This definition shares with the other proposals a scheme that contains three elements: an objective, some means and a reference point.

While many oppose Human Enhancement because of the means it uses (i.e. the recent scientific and technological advances), others object not because the means are objectionable in themselves, but because of when and what they are used for. They are used to improve our capabilities, of course. But improving is a relative and essentially comparative term that needs to be interpreted from a point, from a situation from which to judge and assess the improvement. Hence, when the discussion about Human Enhancement began, it was customary to define it by contrasting it with Therapy. To give just one example, one of the best-known documents on the subject, published in 2003 and prepared by the American President's Council on Bioethics bears the title precisely "Beyond Therapy".

However, the time that has elapsed has made us more and more skeptical about the possibility of going a long way down this road. The debate and the exchange of ideas has been long, and also very interesting insofar as it has made us clarify many terms that are far from being as clear as an innocent reader might think at first glance, such as health and disease, medicine and therapy and, of course, "normal." Although I cannot deal with this issue here with all its complexity (Rodríguez López, 2012), I will say some important things to understand the proposed definition. It can be summed up in very few words: the attempt to distinguish between enhancement therapy is, to quote Ortega, a futile effort that only leads to melancholy.

An attempt, probably the best known, to clarify what we mean by “therapy” says that “therapy aims to fix something that has gone wrong, by curing specific diseases or injuries, while enhancement interventions aim to improve the state of an organism beyond its normal healthy state ”(Bostrom and Roache, 2007). This attempt has the virtue that it is easy to see in it the desperation of the attempt just by asking ourselves what a "normal healthy state" is. For starters, what constitutes a healthy normal state varies throughout an individual's life. If you lose your hair at age 50 you are going through a normal process, but not if you lose it at 15. If you have cataracts at 70 it is normal, but it is not if you have them at 30. In addition, the distinction does not coincide with the medical field and the extra medical. Medicine, especially contemporary medicine, includes many practices that do not fit the definition of therapy offered, such as palliative care, preventive medicine, and some applications of cosmetic surgery.

The distinction between therapy and enhancement is important to the extent that the therapeutic use of certain techniques is considered permissible but the enhancement use is not (Sandel, 2007), that is, to the extent that a role is attributed to it. normative. It is possible to defend it in some contexts, for example to distinguish what should be paid for by social security and what should not. But it is doubtful that it could have a moral relevance. At times, the attempt to improve may be questionable, but that does not make it immoral. We have a good example in cosmetic surgery. It can be in some cases included by public insurance (reconstructive, very small breast or penis, etc.). A woman who pays for her normal-sized breast augmentation out of pocket may be considered superficial, delusional (if she thinks her life will improve), or reckless (undergoes an unnecessary, risky surgical procedure) but not immoral, and It is not seen why the state would intervene to prohibit it.

But there is something that is even more important. Many, if not all, human capabilities are presented in a normal distribution curve (bell curve) in which what is considered above or below the mean value, as well as what is considered above and below normal is a statistical matter. And it changes. Things as disparate as normal height or life expectancy today were far from being a hundred years ago. Because of this, the reference to “normal” must necessarily be contextual, as is done in the proposed definition. The only proposed benchmark is what is considered normal today.