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Exeter College Summer School Professor Julian Savulescu University of Oxford Procreative Beneficence couples (or single reproducers) should (have good normative reason to) select the child, of the possible children they could have, who is expected to have the best life, or at least as good a life as the others, based on the relevant, available information. 3
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford 1
Procreative Beneficence and Disability
Julian SavulescuUehiro Professor of Practical Ethics
University of Oxford
Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
3 Principles of Reproductive Decision Making
1. Procreative Autonomy/Liberty
2. Procreative Beneficence
3. Public Interest
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Procreative Beneficence
• couples (or single reproducers) should (have good normative reason to) select the child, of the possible children they could have, who is expected to have the best life, or at least as good a life as the others, based on the relevant, available information.
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
An Argument in Favour (After Parfit)
• Rubella epidemic– Mutated strain of rubella– Vaccination ineffective– Highly virulent– Women who conceive now are highly likely to have a child deaf, blind or intellectually disabled– If they wait several months, the epidemic will pass and they will likely conceive normal children
– They should wait. It would be wrong to conceive now– Even though no one harmed – disabled child would not be worse off because he/she would not otherwise
have existed– We should select the least disabled child
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Selecting the Best I
• Choline in pregnancy improves IQ• You wish to have a child but the stocks of choline have
run out.• If you wait a month, the stocks will be replenished and
your child will be expected to have a higher IQ• You should wait one month and have a different child
who can be given choline
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Selecting the Best II
• You are having IVF for infertility. • You produce 10 embryos which are going to be tested for chromosomal abnormalities• The doctors ask you if you want a new genetic intelligence profile of your embryos – it
tests for 39 genes using gene chip technology and can give a probabilistic prediction of future IQ
• You should have the profile and choose the embryo expected to have the highest IQ
• Premise: higher IQ makes life go better
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
“Expected to have the best life”
• “Expected” does not mean “will”– Those with the greatest gifts may squander them– Those with significant disabilities may have very good lives
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Decision-theoretic Consequentialism
• One standard way of making decisions under uncertainty is to choose that option which maximizes expected value.
• the expected value of adopting any course of action can be given by: Pr(good outcome given that course taken) X V(good outcome) +
Pr(other outcomes given that course taken) X V(other outcomes).
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Consequentialism
• Consequentialism instructs the agent to: 1. List all the relevant possible courses of action. 2. List the possible outcomes of each action. 3. Estimate the probability that each outcome of each action
will occur, given that the action in question is taken. 4. Assign values to each possible outcome. 5. Calculate the expected value of each possible outcome. This is the product of the value of that outcome
and the probability of it eventuating, given that a particular action is taken. 6. Calculate the expected value of each action. This is the sum of expected values of each the possible
outcomes (or consequences) of that action. 7. Choose the action with the greatest expected value.
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Example: knee replacement
Consider a person trying to decide whether to have a knee replacement for arthritis weigh the pros and cons
• how good/bad these are • how likely they are
– how bad the pain and disability currently are– how much they will be alleviated by the operation– how likely the operation is to be successful– what the risks of the operation are– how bad the complications might be, how much the operation costs, in money and time, and
the consequences of this– what the costs or benefits of waiting are.
• Applies to hearing aid, laser surgery to achieve greater than 20/20 vision (hawk like vision), sonar
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
What is the best life?
• Life with the most well-being • Philosophers have exercised themselves for several thousand years
on what constitutes well-being
– There are various theories of well-being: hedonistic, desire-fulfilment, objective list
» Not just absence of disease.
– People trade length of life for non-health related well-being- smoking, alcohol, risk
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
What is the best life?
• We do have some idea of the good life
Social institutions and scientific research aimed at addressing this
Services to enable people lead good lives
Ask advice
Self help
Education of children
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Disability, Capability and Well-Being
• Well-being how well a life goes (goodness) cannot distribute well-being
• Capability a state of the person which increases the probability of achieving a good life
• Disability a state of the person which decreases the probability of achieving a good life disease is disability
• Moral obligation to promote well-being through increasing capabilities and reducing disabilities
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
What is a disability?
• In 2001, Sharon Duchesneau and Candy McCullough, a deaf lesbian couple had their second child Gauvin• The women, who wanted to have a deaf child, conceived Gauvin through Artificial Insemination by Donor (AID),
using sperm from a friend they knew to have five generations of inherited deafness in his family • They argued that:
– Deafness is an identity, not a medical affliction that needs to be fixed– The desire to have a deaf child is a natural outcome of the pride and self-acceptance many people have of
being deaf– A hearing child would be a blessing, a deaf child would be a special blessing– They would be able to be better parents to a deaf child than to one who was hearing– The child would grow up to be a valued member of a real and supportive deaf community
“Deafness is not a disability”
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Is Deafness a Disability?
• Yes– A deaf person cannot hear music, the sound of wind, the crack of thunder or the seductive
whisper of a lover. – The human voice is a fundamental part of the human condition and verbal communication a
characteristic part of human culture.– Deafness also reduces the chances of realising a good life because it makes it harder to
live, to achieve one’s goals, to engage with others in a world which is based on the spoken word. It is harder to get a job, harder to move in the world, harder to respond to emergencies
– Signing may be a unique mode of communication but it is better to speak two languages than one
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
An example
• On the night of 10th of April, 2003, a school for deaf and mute children in Makhachkala in Russia caught fire.
• Twenty-eight children aged 7 to 14 died and more than 100 were injured.
• “Several children, some naked, jumped through windows to escape the inferno.” Rescuing the children was hampered because “each child had to be awakened individually and told in sign language what to do.”
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Capability/Disability Is Context Dependent
• Deafness is not a disability in a very noisy world; but it is in our world
• Atopic tendency Asthma in developed world Protection against worm infestation in developing world
• X is a disability in circumstances C if: X reduces the chances of a person realising a possible good life
in circumstances C.• In order to decide whether a state is a disability or a capability we need to fix or
predict the social and natural environment
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Biology/Psychology as Capability/Disability
Biological or psychological states can be predicted to be capabilities or disabilities in likely future environments
Our biology contributes not only to our health but to how well our life is likely to go
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Example: Self Control
• In the 1960s Walter Mischel conducted impulse control experiments where 4-year-old children were left in a room with one marshmallow, after being told that if they did not eat the marshmallow, they could later have two. Some children would eat it as soon as the researcher left. Others would use a variety of strategies to help control their
behaviour and ignore the temptation of the single marshmallow.
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Self Control
A decade later, they found that those who were better at delaying gratification had:
• more friends• better academic performance • more motivation to succeed.
Whether the child had grabbed for the marshmallow had a much stronger bearing on their SAT scores than did their IQ.
Impulse control has also been linked to socioeconomic control and avoiding conflict with the law.
Poor impulse control is a disability
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Other Categories
• Buchanan, Brock, Daniels and Wikler: “All Purpose Goods” – Intelligence– Memory – Self- discipline– Foresight– Patience– Sense of humour – Optimism
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Other Categories
– “Hearing can become deaf but the deaf cannot become hearing.”
• Future opportunity-enhancing:– Hearing – 4 limbs– “Open future”
• Future opportunity-restricting– Deafness– Limb amputation (for apotemnophilia)
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Other Categories
• Autonomy enhancing Improving the psychological capacities necessary for autonomy
• concept of self• ability to remember, understand and deliberate on relevant information• strength of will• foresight• empathy, etc
• Our moral character: empathy, imagination, sympathy, fairness, honesty, etc
• Monkeys and grape exoeriment
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Other Specific Examples
• Religiosity – capability or disability?• Criminality
– Dutch family criminality – mutation in the MAO region of X chromosome• Aggression
– Hawking claims genetic modification to reduce aggression is an important strategy in preserving humanity over next 100 years (Guardian 3/8/06)
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
“Genes, not men, may hold the key to female pleasure”
“genes accounted for 31 per cent of the chance of having an orgasm during intercourse and 51 per cent during masturbation”
“ability to gain sexual satisfaction is largely inherited”“The genes involved could be linked to physical differences is sex
organs and hormone levels or factors such as mood and anxiety.”
The Age, June 8, 2005
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Should we enhance/select better people?
“Better people” – more capabilities, less disabilities
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
First Argument for Selection
• 1. Choosing not to select is wrong (other things being equal) Waiting vs selecting If we should wait to have the child with the most capabilities, we should
select
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Selection – after Parfit
• Choosing not to select is wrong (other things being equal)– Conceive a child now – disabled– Wait - normal
– Conceive a child now – IQ 100– Wait and take some intervention – IQ160
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Second Argument: Consistency
• We wait to maximise the environment to give our children the best opportunities – we wait till we have enough money to provide a good education
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Consistency
• There is no difference between environmental and biological intervention Environmental enhancements alter biology Rats given stimulating environment vs prozac
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Consistency
– Environmental manipulations affect biology • Maternal care and stress
– hippocampal development– cognitive, psychological and immune deficits later in life– “Early experience can actually modify protein-DNA interactions
that regulate gene expression,” (changes in methylation of DNA) Michael Meaney
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Third Argument: No difference to disease
• If we accept selection against disease, we should accept selection of capabilities
• Goodness of health is what drives a moral obligation to treat or prevent disease
• Health is not what matters – health enables us to live; disease prevents us from doing what we want and what is good
• But how well our lives goes depends on our biology (in part)
• Drives a moral obligation to enhance and select
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Treatment/Enhancement Distinction
• Habermas, Sandel, Kass – all accept treatment but reject enhancement
• Abortion contraception not treatments but enhancements• Ageing is normal but bad – deafness, memory loss,
impotence• Distinction is arbitrary – statistical. Not of intrinsic
normative significance– Theresa Lewis execution for normal IQ– Picks out what is normally harmful
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Need Diversity
• For Social Reasons– Need cognitive enhancement for social reasons– Low normal IQ as disability
• For Biological Reasons– Introduce massive diversity through gen eng– Need gen selection to protect against gen degen– Not how we deal with epidemic – prevention and treatment
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Change Society, Not People
• We should alter social arrangements to promote well-being, not biologically alter people
• Related: “disability is socially constructed”• Response:
– “Biopsychosocial fit”– We should consider all modifications, and choose the modification, or combination, which is
best• Skin colour
– Social modification and discrimination– Biological modification and environmental risk
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Social Not Biological Enhancement
• Good Reasons to Prefer Social Rather Than Biological Intervention If it is safer If it is more likely to be successful If justice requires it (based on the limitations of resources) If there are benefits to others or less harm If it is identity preserving BUT VICE VERSA
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Social Construction of Disability
• Disability is socially constructed when there are good reasons to prefer social intervention than direct biological or psychological intervention.
• Biopsychosocial construction of disability: Must consider reasons for and against intervention at all levels:
• Social• Psychological • Biological
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Society Benefits from Variety/Disability
Not obviously true – psychopathyEvolutionary accidentNot clear that the current balance is optimal – status quo biasThere will always be variety/disability by choice and by accidents/disease
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Discriminination
• a two class society of the enhanced and the unenhanced, where the inferior unenhanced are discriminated against and disadvantaged all through life Gattaca
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Responses
– Nature alots advantage and disadvantage with no mind to fairness – natural inequality
• Some are born horribly disadvantaged, destined to die after short and miserable lives.
• Some suffer great genetic disadvantage while others are born gifted, physically, musically or intellectually.
• nothing fair about the natural lottery• allowing enhancement could be used to reduce natural inequality.
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Egalitarian social institutions
– how well the lives of those who are disadvantaged go depends not on whether enhancement is permitted, but on the social institutions we have in place to protect the least well off and provide everyone with a fair go.
• People have disease and disability – egalitarian social institutions and laws against discrimination are designed to make sure everyone, regardless of natural inequality, has a decent chance of a decent life.
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Discrimination
• How the biologically modified and unmodified are treated is our choice
• Equal concern and respect is possible in a world of biological modification
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Self-defeating (or Unfair)
• If everyone stands on tiptoes, no one sees better– But distinguish between
• positional goods – height• Non-positional goods - memory
• Question of justice – not particular to biological modification
• If significant, make it free, like health care
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Parker’s Objection: Value of Loss, Suffering, Limitation and Mystery of Life
• President’s Commission’s Beyond Therapy– “Traumatic memories, shame, and guilt, are, it is true, psychic
pains. In extreme doses, they can be crippling. Yet, short of the extreme, they can also be helpful and fitting. They are appropriate responses to horror, disgraceful conduct, injustice, and sin, and, as such, help teach us to avoid them or fight against them in the future.”
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Beyond Therapy
• “there appears to be a connection between the possibility of feeling deep unhappiness and the prospects for achieving genuine happiness. If one cannot grieve, one has not truly loved. To be capable of aspiration, one must know and feel lack. The world would be a sterile, monotonous place where everyone is the same, and the mystery and surprise of life is gone.”
• Michael Sandel: we must be “open to the unbidden”
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Shakespeare
– ‘The web of our life is of mingled yarn, good and ill together; our virtues would be proud if our faults whipp’d them not, and our crimes would despair if they were not cherish’d by our virtues.’
• “All’s Well that Ends Well”» [Mike Parker]
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Responses
– Introduce suffering, difficulty, light and dark– Not all will enhance – 10% choose not to abort Down syndrome– There will be plenty of challenge and mystery left in an uncertain
world– Better children may be possible; perfect children will not
• One can choose to go to a good play rather than a poor one, and still experience the mystery of events as they unfold.
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Fails to Respect or Promote Value
• Habermas: communicative dialogue• Sandel: humility and solidarity• Fail to respect autonomy
• If X is to be respected or of value, then select or enhance X
• Status quo bias to assume everyone in all circumstances has enough X
48
Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Cheating
• Only if rules ban it• Key issue is safety – caffeine
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Inauthentic
• Achievement is product of selection or enhancement – like doping in sport– But why think we deserve credit for natural lottery– Depends on effort and will exerted, and volume of contribution of
enhancement– Effort and struggle still required to be best– Enhancemetn can be expression of authenticity – becoming the
person you really want to be
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Open Future
• Fails to respect child’s open future; Sandel: hyperparenting
• But how child is treated is independent from selection or enhancement
• Resilience to abuse – high MAOA• Some choices enhance future options – all purpose
goods• Some decisions must be made for child • Options are closed as a part of parenting – schooling
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Skepticism about Value and Moral Relativism
• Cant tell what is of value/relative to culture/time/etc– False– Disability/capabity are context specific– Universal human values – human rights
• Mixed value – manic depression– No precise cardinal ranking – black, white and grey– Some states are clearly better than others – what would you
preserve or aim for in education/diet
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Conclusion
• 21st century medicine and medical research should be to develop interventions which not only prevent and treat disease, but make people’s lives better.
• Natural inequality exists– Genetic selection is the first of these– Future:
• Genetic engineering – artificial chromosomes• Internal technology – nanotechnology, artificial intelligence
• Scientific and medical research is the way to realise this future
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
• “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.” – George Bernard Shaw, Man and Superman IV.
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Conclusion
• Shaw is wrong Sometimes it is rational to adapt biologically or
psychologically to the world Sometimes, we should select our children to have good
lives in the world as it is likely to be Sometimes it is rational to change the world Sometimes, we should accept things just as they are
• Which course of action or inaction we choose depends on the benefits and risks, the opportunity costs and the context
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Exeter College Summer SchoolProfessor Julian Savulescu
University of Oxford
Obligation to Consider Enhancement and Selection
• What we must do is consider all options and make an active choice which reason supports
• We have good reason to be better and to select children who are expected to have better lives
• We can no longer leave our lives thoughtlessly to chance
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