Ethical issues in moral and social enhancement

prima facie
warranted. The 
OCD symptoms are thought to be maintained by faulty beliefs, e.g., the belief that 
having a thought is morally no different from doing a bad thing (what psychologists 
call ‘thought-action fusion’)
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and that having a thought about harming one’s child 
means that there is a significant actual danger of doing harm. Another concern 
about the review of actions in the presence of a strong compulsion is related to the 
question of whether or not such review is all-things-considered. A more specific 
question to be asked in the context of MB-induced compulsions is whether or not, 
and to what extent, the presence of strong impulses 
precludes
an appropriate all-
things-considered review.
Although the example of OCD is useful in demonstrating the possibility of 
preserving review in the presence of strong compulsions, the example is of limited 
utility in considering whether or not the presence of MB-induced compulsions 
would impair the quality of moral review. Since OCD is treated as a disorder, 
something did go wrong at some point.
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Even if the quality of all-things-
considered review would be impaired in this population, it would be unclear 
whether or not this impairment is due to the presence of compulsions or some other 
characteristics of that population.
fact that OCD patients do not usually act on their imagining that the thoughts are 
‘motivation-less’ as the fact that the desire is not effective does not mean that there is no 
motivational component at all; moreover, I have not encountered any indication of lack of 
such motivational component of the intrusive thoughts in the literature on OCD. 
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Note that although I have earlier argued that motivations on which we act should be 
considered together with actions in assessment of moral responsibility (and are thus 
‘joined’ for the purposes of such assessment) this does not commit me to problematic 
positions entailed in ‘though-action fusion.’ Accepting actions and their motivational 
underpinnings as the unit of moral responsibility assessment entails neither that we are 
responsible for our thoughts without any regard to actions, nor that we are responsible for 
every single one of our thoughts, nor that thinking about doing something is as morally 
good or bad as actually doing it.
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This point is related to the discussion of medicalization in Chapter 5. The construction of 
a certain way of thinking or acting as a medical condition often includes the assessment of 
it as in some way harmful or undesirable, thus making it a value-laden process. This 
assessment may include the reference to ideas about agency, moral agency including.

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However, let us suppose that the above problem does dissuade us from attempting 
to make an argument that OCD indicates that strong compulsions preclude all-
things-considered judgement moral review of a sufficient quality. There are further 
problems with such a line of argument. The first problem relates to the influence of 
faulty beliefs. It is a matter of discussion whether the 
process
of the all-things 
considered judgement is faulty or whether the process is comparable to non-OCD 
population, with the problem here lying in the influence of faulty 
beliefs
. There is 
some indication that faulty beliefs are an important factor. CBT treatment for OCD 
focuses in the first instance on changing faulty beliefs by examining them in talking 
therapy, confronting the beliefs with reality by exposure and habituating the patient 
to the anxiety that the thoughts evoke. It would seem that the main target in CBT is 
change of beliefs and integrating them into the process of emotional responses, 
rather than enhancing all-things-considered judgement. The conclusion we can 
justifiably take away from this is a modest one – that the review in general and 
moral review specifically is influenced by the beliefs that a person holds. Little can 
be concluded about the quality of the process of review in comparison to those not 
afflicted by strong compulsions.
The second problem is related to the direction of the causal influence. Post-partum 
OCD often arises in patients with previous OCD characteristics. This indicates that 
it is not the occurrence of a particular strong impulse or inclination that leads to the 
development of OCD; the causal influence is more likely to go the other way round. 
Many new parents may experience a thought or impulse to harm their child (similar 
to the impulse to hit when we are very angry), which when not acted upon, 
unendorsed and not given much weight, simply diminishes with time or is not a 
problem. It seems that the way OCD patients respond to such impulses contributes 
to their maintenance. As a result, although OCD is a good example of a moral 
review present 
alongside
compulsions, it is not a good example of 
compulsion-
induced
impairment
in moral review.
Assessing the extent to which the ability for 
online
review is preserved in the 
presence of strong compulsions is more difficult. I am not aware of 
phenomenological data that clearly assesses the kind and quality of awareness and 

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moral review while the patient experiences intrusive thoughts and performs 
ritualistic compulsive actions, nor data from other compulsive behaviours such as 
binge eating.
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An additional problem is that for the argument about the impairing 
effects of compulsions on online moral review, we would have to have similar data 
about a matched population not afflicted by compulsions. Since neither are present, 
we have to work here on best guesses.
Patients’ reports such as the one cited above provide some indication that online 
review is to some extent present at all times and that online review is strengthened 
by therapeutic interventions (Denys, 2011). Moreover, the reports of the feeling of 
‘loss of control’ during compulsive or impulsive episodes indicate the presence of 
online review (O’Guinn and Faber, 1989). Such feeling presupposes a degree of 
online review happening, even if the ability for online control is impaired. The 
possibility of the presence of online moral review is also implicitly indicated in 
cases of successful attempts for online control that is a common experience for 
many of us – even when we are very angry we might judge it inappropriate to act 
on that anger, realise that our anger is disproportionate to the stimulus and go for a 
head-cooling walk instead of acting on the anger-related impulses. Moreover, even 
if we fail to resist following angry impulses, we might act knowing ‘at the back of 
our head’ that we should not. This provides support for the practical plausibility of 
the dissociation between moral review and moral control both online and offline. 
Moreover, it seems that ability for online moral review can be preserved even in the 
presence of strong compulsions or impulses and is separable from online control.