If there existed an innocuous drug that could improve your cognitive abilities and performance, would you take it?
Historically, humans have always spoken of a state of being beyond the human potential; a few examples are immortality, superhuman strength, omnipotence, and psychic power. Today, shelves on drug stores abound with pills, drinks, and tonics that purportedly improve IQ, memory, endurance, alertness, and mental focus. Increased prevalence of “cosmetic neurology,” the off-label and non-prescription use of drugs to enhance performance rather than to treat an existing condition, has caught the attention of the media and the scientific community (Chatterjee, 2004.) In particular, “nootropics,” smart drugs used to augment cognitive performance and abilities, present a divisive issue for both scientists and the public sector (Farah et al., 2004; Racine & Forlini, 2008; Greely et al., 2008; Fukuyama, 2002; Cakic, 2009; Turner, 2002; McCabe, 2005.) Recent studies demonstrate an increased prevalence of nootropics on college campuses to enhance academic performance (McCabe, 2005; Diller, 1996.) While only 4-7% of US college students are diagnosed with attention deficit hyperactive disorder (ADHD) using DSM IV criteria, up to 25% of college students on a given campus reported having used stimulants meant for ADHD in the previous year (Weyandt, 2006; McCabe, 2005; Teter, 2006.) Staggering figures regarding academic doping has initiated a furious effort by scientists, ethicists, medical practitioners, and the government to discuss potential ethical implications of cognitive enhancements and future directions. For future policymakers to tackle this issue, this paper will lay a preliminary ethical framework for considering future nootropic regulation. The considerations discussed in this paper are not novel as they apply in many aspects to other pharmacological or non-pharmacological substances that could alter performance and leverage an unfair advantage between groups of individuals. However, these concerns coalesce in a novel way in regards to the use of nootropics because their effects can also alter the human mind, a consecrated part of the human existence. Four salient ethical concerns raised by the use of nootropics that are often addressed in regards to health care allocation will be discussed: 1) safety, 2) distributive justice, 3) coercion, and 4) personhood.
As the field stands, the drug most often used for non-medical purposes is methylphenidate (Ritalin). Methylphenidate is a stimulant used to treat ADHD in adults and children and has been shown to improve attention, concentration, spatial working memory, and executive planning (Solanto, 1998; Pary, 2002; Weber, 2002.) The effects of methylphenidates are thought to be modulated through the catecholamine system (Solanto, 1998.) Modafinil (Provigil), a drug developed for the treatment of narcolepsy with a similar clinical profile to methylphenidate, has also been shown to be effective in the treatment of ADHD (Taylor & Russo, 2000.) Despite certain similarities to methylphenidate, modafinil does not act through the catecholamine pathway, although the exact mechanism is unknown (Ferraro, 1996; 1997.) Other studies have shown that this drug also improves arousal, improves alertness, and improves sustained attention in sleep deprived subjects (Lagarde, 1995; Caldwell, 2000; Dodds et al., 2009.) The aforementioned improvements were observed in individuals with ADHD, a demonstrated neurological condition, which would benefit from pharmaceutical treatment to restore the brain to normal functioning. In healthy individuals, results have been inconclusive in regards to the benefits of methylphenidate and modafinil; in general the results have demonstrated selective conditional improvements (Turner, 2002; Agay, 2010.) Although these drugs do not incontrovertibly enhance cognitive performance, they pose a unique ethical quandary that has never been addressed by physicians and scientists. That is, what should we, as a society, do in regards to cognitive enhancements?
What is the purpose of medicine?
This question lies at the heart of the issue of cognitive enhancements. Arguably, the answer could either be to improve the quality of life for patients or to treat diseases. One view argues that the purpose of medicine is to improve the quality of life for the patients by curing their ailments and returning them to a state where they subjectively felt better, and therein lays the problem. Chatterjee discusses the dissonance between the perspectives of medical practitioners and their patients on the issue of quality of life (2004.) While the focus of allopathic medicine has been to treat and cure diseases, treatment of disease symptoms does not necessary improve the quality of life for patients. It could be said that for patients with incurable diseases, it would be more beneficial to improve their quality of life instead of targeting individual symptoms through the use of pharmaceuticals. For example, in Parkinson’s disease, treatment using dopamine agonists can actually induce negative side effects such as nausea, vomiting, psychosis, and dyskinesia (Schrag, 2000; Chapuis, 2005.) The benefits gained from alleviating Parkinson’s symptoms in this case could be overshadowed by the negative side effects of the medication, thus further decreasing the quality of life for the patient.
Assuming that the purpose of medicine is to improve quality of life for patients, we then reach yet another ethical quandary. Who is a patient? Should only those who are ill be allowed access to medicine or should all individuals be eligible for medical help. Further, should illness be defined as a mental, biological, behavioral condition or some combination of those factors? If one were to say that medical services should be limited to the ill, then there would be no need for preventive care, since those individuals are not yet ill. In light of the fact that preventive care is an integral part of medicine, one must assume that all individuals, regardless of current health status must qualify for medical care. Then, if improving the quality of life for a diseased individual means alleviating bothersome adverse symptoms, what would that mean for a healthy individual? Would that mean that transcending beyond the “normal” human condition and enhancing baseline performance are inherent parts of medicine?
While the use for pharmaceuticals for treatment of diseases is undisputedly supported by the general public, the use of pharmaceuticals for enhancements is much more controversial (Chatterjee, 2004; Racine & Forlini, 2008.) Perhaps one reason why the use of cognitive enhancements is so contentious is because it alters the status quo of the human condition. Historically, humans have been very resistant to change until a catalyst triggers an indisputable paradigmatic shift. Until then, scientists, ethicists, practitioners, and the general public are often divided between different camps of thought, each operating on separate paradigms. As discussed by Racine and Forlini, the different paradigms include cognitive enhancements as a beneficial inevitability of human development, cognitive enhancements as abuse of prescription drugs, and cognitive enhancements as a lifestyle choice (2008.) Even within the realm of academia, there is no widely accepted paradigm. Greely et al. and other prominent academics strongly advocate the responsible use of cognitive enhancements, defending its potential benefits under proper regulation while practitioners like Chatterjee and philosophers like Fukuyama disagree (Greely et al. 2008; Farah et al., 2004; Harris, 2009; Fukuyama, 2002; Chatterjee, 2009.) Fukuyama maintains in his book Our Post Human Future that “the original purpose of medicine is to heal the sick, not turn healthy people into gods. (p.208, 2002)” In order to move closer to a unified and, more importantly, informed policy decision regulating the use of cognitive enhancement, it is necessary to consider the following ethical concerns: safety, distributive justice, coercion, and personhood.
Are the benefits worth the risk?
The first ethical concern that one should consider is the safety of the patient. In protecting the safety of the patient, one must consider the safety profile of the cognitive enhancement in question. When a patient is placed on a drug, the doctor and patient must carefully evaluate the balance between the desired benefits and the risks. Patients often choose to take drugs with serious risks because the potential benefits are much greater; an example would be chemotherapeutic agents. Of course, the benefits of drugs are heavily affected by the disease curing factor. Since cognitive enhancements in healthy individuals are not meant to cure any particular diseases, the tolerance for risks is severely lowered (Farah et al., 2004; Cakic, 2009; Butcher, 2003.) Thus, nootropic agents should be subjected to the same, if not more stringent considerations as other drugs in regards to safety (Chatterjee, 2006.) Greely et al. and colleagues propose accelerating the research process to discover the mechanism of action for various enhancements, to allow patients and doctors to make a fully informed decision that would maximize benefit and minimize harm (Greely et al., 2008.) Certain clinicians may feel that any potential risk to a healthy individual should not be tolerated, thus, cognitive enhancements should not be made available (Chatterjee, 2004; 2006.) However, these clinicians would be remiss in denying patient autonomy. When fully informed of the potential risks and benefits, a patient has every right to decide for himself/herself the course of treatment (Quill & Brody, 1996.) Thus, the role of the clinicians and legislator would be a fine balance between considerations for patient safety and maintaining patient autonomy. Although the individual responsibilities of clinicians and legislators are different, conversations must be facilitated between the two groups in order to reach an optimal solution to the regulation of cognitive enhancements. If cognitive enhancements pose undisputed and unavoidable threats to patient safety, the clinicians and legislators are within their rights, and are duty bound, to protect the patients from such substances. However, if the side effects are not detrimental to society as a whole and the enhancement would not cause unavoidable harm, then the decision for use should be that of the patient’s. What constitutes societal detriments would be determined by a collaboration between physicians and legislators, taking into consideration effects on health and individuals. Most importantly, as suggested by Greely et al. and colleagues, it is the role of the scientists to ensure that results of their scientific studies are correctly portrayed and employed to aid educated decisions (2008.)
Would enhancements provide equal benefits to all?
The second ethical concern is distributive justice. If cognitive enhancements were made available, would the availability of the drugs naturally prove advantageous to some while disadvantaging others? As with all free-market goods, cognitive enhancements would conceivably benefit the wealthy more than the economically disadvantaged. Moreover, if cognitive enhancements augment cognitive ability beyond normal capacity, then the wealthy would have greater means and opportunity to obtain these cognitive enhancements, monopolizing the market on the new cognitive norm (Butcher, 2003.) In regards to use of nootropics in an academic setting, one could contend that nootropic use would create an uneven playing field, allowing those who can afford the enhancements to outperform those who cannot. This would create a cyclical effect on education and employment disadvantaging those who do not have the means to reach the new norm in the end. However, to say that the availability of cognitive enhancements as free-market goods would generate a novel uneven field would be naïve. Disparities already exist in terms of biological and environmental incongruities between the socioeconomic classes (Farah, 2002.) Farah et al. argue that education is an unequally distributed cognitive enhancer that is tolerated by society, thus, prohibiting the use of cognitive enhancements on the grounds of unequal distribution would be superfluous and hypocritical (2002; 2004; Butcher, 2003.) If anything, it may be easier to ensure the equal distribution of cognitive enhancement than it is to ensure equal education opportunities due to the fact that there are many factors contributing to education inequalities (eg. location, economic wealth, etc…) (Butcher, 2003.)
Would cognitive enhancers indirectly cause peer pressure for use?
The third ethical concern is coercion. There are two forces of coercion: implicit desire to maintain the status quo, and explicit demands to fulfill and exceed pre-determined expectations (Chatterjee, 2004.) Many fear that if cognitive enhancements were made readily available, then those who chose not use them would be implicitly and explicitly coerced by their peers in order to remain competitive. The extreme case would be regulations demanding use of cognitive enhancements for those working in the public sector to meet customer demands. An example cited by Chatterjee is based on previous findings of improved performances of pilots in emergency situation while taking donezepil (Chatterjee, 2004; Yesavage, 2001.) Would the customers of the airlines be justified in demanding that all pilots be taking donezepil? Would this be ethical? Would customers even need to make such demands since pilots may then feel pressured to take donezepil to make increase their attractiveness in the job market? As before, it would be ignorant to think that such forces of coercion do not exist in today’s society. Studies have shown that the incidence of non-medical prescription stimulant use is higher among US college students with lower grade point averages, suggesting that these students already feel pressured to use stimulants to keep up with their peers in the competitive academic environment (McCabe, 2005.) Cakic posits that in order for a student to feel implicitly coerced to use cognitive enhancements, two criteria must be met: 1) students who use cognitive enhancements would have a distinct advantage over those who do not, and 2) a significantly high portion of the student population must be using cognitive enhancements (Cakic, 2009.) Without extensive empirical data, it would be difficult to assess the coercive forces at play in today’s society, especially in academia where cognitive enhancement use would be most prevalent. It would be difficult to make a clear policy decision based on this factor alone.
How will the user’s perception of self change?
The final ethical consideration is personhood, or one’s perception of oneself. Understandably, critics are wary of psychoactive substances and their potential impact on the perception of self. Further, there is an argument that an integral part of humanity, or rather our notion of personhood, would be at risk if one were to use cognitive enhancements (Butcher, 2003; Chatterjee, 2004; Wolpe, 2002.) By personhood, these critics are referring to the quintessential essence of human suffering; the very act of striving toward a goal defines that individual’s identity as perceived by others and their own self-identity. Cognitive enhancements would provide shortcuts to individuals, bypassing some of life’s necessary and formative struggles, thus altering an individual’s personhood and definition of self (Wolpe, 2002.) Wolpe refers to struggles such as the late night persevering to learn a new subject or skill (2002.) Of course, the opposing viewpoints could assert that today’s society, equipped with perpetually changing technology permits individuals to redefine, reinforce, or even rebuild their identities, and the use of cognitive enhancements would simply be integrated into those processes.
Are we ready?
This paper discussed several key ethical dilemmas involved in the issue of cognitive enhancements. Although current drugs used with the intention of enhancing cognitive abilities have shown little to no significant improvements in healthy individuals, it is still important to begin the investigative process by assessing the validity of existing and novel ethical stances. Further, in order to reach a fully informed decision that is in the best interest of society, there must be collaboration and communication between scientists, practitioners, ethicists, legislators, and the general public. Firstly, scientists and physicians must determine the ramification of prolonged use of cognitive enhancements on our brains, delineating the morphological, behavioral, and cognitive effects. From these findings, it would be possible to assess the degree of impact these enhancements will have on an individual and how that impact will translate to society as a whole. Legislators and ethicists must then interpret these results and determine necessary regulations in terms of manufacturing and distribution. Ideally, this process would occur first at the national level then on a global scale to ensure that countries would not capitalize upon this opportunity to coin a new type of warfare, “intelligence warfare.”
While we are not yet at a stage where a drug incontrovertibly enhances cognitive abilities beyond normal capacity, it is necessary that we set up the framework to best accommodate future situations. With developments not just in pharmaceuticals but technological advancements, it is plausible that these considerations will be employed sooner rather than later.
Agay, N., Yechiam, E., Carmel, Z., & Levkovitz, Y. (2010). Non-specific effects of methylphenidate (Ritalin) on cognitive ability and decision-making of ADHD and healthy adults. Pgchopharmacology, 210(4), 511-519. doi:10.1007/s00213-010-1853-4
Bichonski, R. (1975). [Analysis of clinical phenomena and changes in physico-chemical properties of the blood in mentally ill children]. Folia Medial Cracoviensia, 17(3), 313-328.
Butcher, J. (2003). Cognitive enhancement raises ethical concerns. The Lancet, 362(9378), 132-133. doi:10.1016/S0140-6736(03)13897-4
Cakic, V. (2009). Smart drugs for cognitive enhancement: ethical and pragmatic considerations in the era of cosmetic neurology. Journal of Medical Ethics, 35(10), 611-615. doi:10.1136/jme.2009.030882
Caldwell, J. A., Caldwell, J. L., Smythe, N. K., & Hall, K. K. (2000). A double-blind, placebo-controlled investigation of the efficacy of modafinil for sustaining the alertness and performance of aviators: a helicopter simulator study. Psychopharmacology, 150(3), 272-282.
Chapuis, S., Ouchchane, L., Metz, 0., Gerbaud, L., & Durif, E (2005). Impact of the motor complications of Parkinson’s disease on the quality of life. Movement Disorders, 20(2), 224-230. doi:10.1002/ mds.20279
Chatterjee, A. (2006). The promise and predicament of cosmetic neurology. Journal of Medical Ethics, 32(2), 110-113. doi:10.1136/ jme.2005.013599
Chatterjee, A. (2009). Is it acceptable for people to take methylphenidate to enhance performance? No. BMJ, 338(jun18 2), b1956-b1956. doi:10.1136/bmj.b1956
Chatterjee, A. (2004). Cosmetic neurology: the controversy over enhancing movement, mentation, and mood. Neurology, 63(6), 968-974.
Diller, L. H. (1996). The run on Ritalin. Attention deficit disorder and stimulant treatment in the 1990s. The Hastings Center Report, 26(2), 12-18.
Dodds, C., Muller, U., & Manly, T. (2009). Effects of Psychostimulants on Alertness and Spatial Bias in Healthy Participants. Journal of Cognitive Neuroscience, 21(3), 529-537. doi:10.1162/jocn.2009.21046
Farah, M. J. (2002). Emerging ethical issues in neuroscience. Nature Neuroscience, 5(11), 1123-1129. doi:10.1038/nn1102-1123
Farah, M. J., Illes, J., Cook-Deegan, R., Gardner, H., Kandel, E., King, P., Parens, E., et al. (2004). Science and Society: Neurocognitive enhancement: what can we do and what should we do? Nature Reviews Neuroscience, 5(5), 421-425. doi:10.1038/nrn1390
Ferraro, L., Antonelli, T., Oconnor, W, Tanganelli, S., Rambert, E, & Fuxe, K. (1997). Modafinil: An antinarcoleptic drug with a different neurochemical profile to d-amphetamine and dopamine uptake blockers. Biological Psychiatry, 42(12), 1181-1183. doi:10.1016/ S0006-3223(97)00353-3
Ferraro, L., Tanganelli, S., Oconnor, W, Antonelli, T., Rambert, E, & Fuxe, K. (1996). The vigilance promoting drug modafinil decreases GABA release in the medial preoptic area and in the posterior hypothalamus of the awake rat: possible involvement of the serotonergic 5-HT receptor. Neuroscience Letters, 220(1), 5-8. doi:10.1016/S0304-3940(96)13212-2
Fukuyama, E (2003). Our posthuman future : consequences of the biotechnology revolution (1st ed.). New York: Picador.
Greely, H., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., Campbell, P., & Farah, M. J. (2008). Towards responsible use of cognitive-enhancing drugs by the healthy. Nature, 456(7223), 702-705. doi:10.1038/456702a
Harris, J. (2009). Is it acceptable for people to take methylphenidate to enhance performance? Yes. BMJ, 338(jun18 2), b1955-b1955. doi:10.1136/bmj.b1955
Lagarde, D., Batejat, D., Van Beers, P., Sarafian, D., & Pradella, S. (1995). Interest of modafinil, a new psychostimulant, during a sixty-hour sleep deprivation experiment. Fundamental & Clinical Pharmacology, 9(3), 271-279.
McCabe, S. E., Knight, J. R., Teter, C. J., & Wechsler, H. (2005). Nonmedical use of prescription stimulants among US college students: prevalence and correlates from a national survey. Addiction,100(1), 96-106. doi:10.11114.1360-0443.2005.00944.x
Pary, R., Lewis, S., Matuschka, P., Rudzinskiy, P., Safi, M., & Lippman, S. (n.d.). Attention deficit disorder in adults. Annals of Clinical Psychiatry, 14, 105-111.
Quill, T. E., & Brody, H. (1996). Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Annals of Internal Medicine, 1 2 5(9), 763-769.
Racine, E., & Forlini, C. (2008). Cognitive Enhancement, Lifestyle Choice or Misuse of Prescription Drugs? Neuroethics, 3(1), 1-4. doi:10.1007/s12152-008-9023-7
Schrag, A., Jahanshahi, M., & Quinn, N. (2000). How does Parkinson’s disease affect quality of life? A comparison with quality of life in the general population. Movement Disorders, 15(6), 1112-1118. doi:10.1002/1531-8257(200011)15:6<1112::AIDMDS1008>3.0.00;2-A
Solanto, M. (1998). Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. Behavioural Brain Research, 94(1), 127-152. doi:10.1016/S0166-4328(97)00175-7
Taylor, E B., & Russo, J. (2000). Efficacy of modafinil compared to dextroamphetamine for the treatment of attention deficit hyperactivity disorder in adults. Journal of Child and Adolescent Psychopharmacology, 10(4), 311-320.
Teter, C. J., McCabe, S. E., LaGrange, K., Cranford, J. A., & Boyd, C. 1. (2006). Illicit Use of Specific Prescription Stimulants Among College Students: Prevalence, Motives, and Routes of Administration. Pharmacotherapy, 26(10), 1501-1510. doi:10.1592/ phco.26.10.1501
Turner, D., Robbins, T., Clark, L., Aron, A., Dowson, J., & Sahakian, B. (n.d.). Cognitive Enhancing Effects of modafinil in Healthy Volunteers. Psychopharmacology, 165(3), 260-269.
Weber, P., & Lutschg, J. (2002). Methylphenidate treatment. Pediatrics Neurology, 26, 262-266.
Weyandt, L. L. (2006). ADHD in College Students. Journal of Attention Disorders, 10(1), 9-19. doi:10.1177/1087054705286061
Wolpe, P. (2002). Treatment, enhancement, and the ethics of neurotherapeutics. Brain and Cognition, 50(3), 387-395. doi:10.1016/50278- 2626(02)00534-1
Yesavage, J. A., Mumenthaler, M. S., Taylor, J. L., Friedman, L., O’Hara, R., Sheikh, J., Tinklenberg, J., et al. (2002). Donepezil and flight simulator performance: effects on retention of complex skills. Neurology, 59(1), 123-125.
Dejongh, R., Bolt, I., Schermer, M., & Olivier, B. (2008). Botox for the brain: enhancement of cognition, mood and pro-social behavior and blunting of unwanted memories. Neuroscience & Biobehavioral Reviews, 32(4), 760-776. doi:10.1016/j.neubiorev.2007.12.001
Lanni, C., Lenzken, S., Pascale, A., Delvecchio, I., Racchi, M., Pistoia, E, & Govoni, S. (2008). Cognition enhancers between treating and doping the mind. Pharmacological Research, 57(3), 196-213. doi:10.1016/j.phrs.2008.02.004
Rose, S. P. R. (2002). ‘Smart drugs’: do they work? Are they ethical? Will they be legal? Nature Reviews. Neuroscience, 3(12), 975-979. doi:10.1038/nrn984
Swanson, J. M., & Volkow, N. D. (2009). Psychopharmacology: concepts and opinions about the use of stimulant medications. Journal of Child Psychology and Psychiatry, 50(1-2), 180-193. doi:10.1111/ j.1469-7610.2008.02062.x
Vastag, B. (2004). Poised to Challenge Need for Sleep, “Wakefulness Enhancer” Rouses Concerns. JAMA: The Journal of the American Medical Association, 291(2), 167-170. doi:10.1001/jama.291.2.167