The value and pitfalls of speculation about science and technology in bioethics: the case of cognitive enhancement
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In the debate on the ethics of the non-medical use of pharmaceuticals for cognitive performance enhancement in healthy individuals there is a clear division between those who view “cognitive enhancement” as ethically unproblematic and those who see such practices as fraught with ethical problems. Yet another, more subtle issue, relates to the relevance and quality of the contribution of scholarly bioethics to this debate. More specifically, how have various forms of speculation, anticipatory ethics, and methods to predict scientific trends and societal responses augmented or diminished this contribution? In this paper, we use the discussion of the ethics of cognitive enhancement to explore the positive and negative contribution of speculation in bioethics scholarship. First, we review and discuss how speculation has relied on different sets of assumptions regarding the non-medical use of stimulants, namely: (1) terminology and framing; (2) scientific aspects such as efficacy and safety; (3) estimates of prevalence and consequent normalization; and (4) the need for normative reflection and regulatory guidelines. Second, three methodological guideposts are proposed to alleviate some of the pitfalls of speculation: (1) acknowledge assumptions more explicitly and identify the value attributed to assumptions; (2) validate assumptions with interdisciplinary literature; and (3) adopt a broad perspective to promote more comprehensive reflection. We conclude that, through the examination of the controversy about cognitive enhancement, we can employ these methodological guideposts to enhance the value of contributions from bioethics and minimize potential epistemic and practical pitfalls in this case and perhaps in other areas of bioethical debate.
KeywordsCognitive enhancement Methods of bioethics Speculation Neuroethics Reflexivity
The debate about the phenomenon of “cognitive enhancement”, namely the non-medical use of pharmaceuticals to augment cognitive performance in healthy individuals, has raised wide-ranging ethical questions and captured attention within academia and broader society (Farah et al. 2004; Parens 1998; Greely et al. 2008). This debate has led to proposals for public policy (Outram and Racine 2011a, b), to extensive and high profile media coverage (Forlini and Racine 2009a, b; Boot et al. 2011; Partridge et al. 2011), to publications for the general public (Buchanan 2011), and to heated academic exchanges (Caplan and Elliott 2004; Caplan and McHugh 2004). There is a clear division between those who are generally in favor of enhancement and those who see such practices as ethically problematic (Parens 2005; Racine 2010; Forlini and Racine 2013). This paper focuses on the way that scholarly bioethics, defined as broadly encompassing contributions from authors with diverse disciplinary backgrounds such as bioethics, neuroscience, philosophy, and law, has been conducted in the cognitive enhancement debate. It examines how various forms of speculation, anticipatory ethics, and methods to predict trends have augmented or diminished the relevance and quality of the work in scholarly bioethics. Some authors are engaging in the prediction of future outcomes (e.g., benefits or risks of human enhancement) and trends related to the use of pharmacological cognitive enhancers (Bostrom and Sandberg 2009) and others are criticizing such speculation (Lucke et al. 2010; Carter et al. 2009).
Speculation, or “looking out” (speculare), involves an attempt to predict and draw conclusions based on incomplete evidence. In this paper, we consider speculation about the future as an effort to foresee potential or probable scenarios and their outcomes based on assumptions that cannot be verified by empirical or scientific claims in the present. Although this form of “looking out” is future-directed, the specific act of speculation takes place in the present, which means that the act of speculation is always situated within present values and concerns. To “look out” necessarily implies looking out from a particular place, or a particular point of view, towards an unknown future and thus, there are multiple ways to “look out”. Speculation is a challenging exercise because of the interdisciplinary and multi-faceted nature of bioethical inquiries and the complexity of the questions they raise, as is the case with cognitive enhancement. In addition, we recognize the positive value of speculation and of creative, forward-looking, moral thinking to generate responses to ethical problems posed by biomedical science (Keulartz et al. 2004). Nevertheless, the process is not without pitfalls. Here, we consider specifically the problems regarding how some unwarranted speculation has occurred about cognitive enhancement and caused serious detrimental effects within scholarly bioethics.
In this paper, we use the ethical discussion of cognitive enhancement as a case study to explore the positive and negative contribution of speculation in bioethics scholarship. We first establish how speculation was involved in framing and supporting the debate on cognitive enhancement practices and highlight related concerns. We then propose and reflect on a number of methodological guideposts to avoid practices in which speculation runs the risk of degenerating into unfounded and inaccurate claims. We argue that claims made about the future practices of cognitive enhancement be done with clearer factual constraints, more awareness, and enhanced self-reflection. We hope to stimulate further discussion on the methods of bioethics scholarship with respect to speculation and its impact on public debate. Other topics such as gene “therapy”, xenotransplantation, stem cell “therapy,” nanotechnologies, reproductive technologies and other related technologies, which have raised ethical questions, would be suitable for similar analysis. The case of cognitive enhancement is particularly suited for further consideration because the non-medical use of stimulants is a documented practice in some regions and offers a unique case study of how speculative discourses may come to shape concrete reality (Dresler et al. 2013; ETHENTECH 2012; Neuro-Enhancement: Responsible Research and Innovation 2013).1
Speculation in discussions about cognitive enhancement
In bioethics, the nature of and justification for speculation are multifaceted. In some respect, speculation is a deliberate effort to conduct proactive ethics. The purpose is to foresee the major ethical challenges in an effort to minimize harms that may be caused by, in this case, the non-medical use of pharmaceuticals. In this sense, speculation is at the root of the early impetus for a renewed biomedical ethics (Durand 1999). At the same time speculation necessarily relies on unknowns and is a practice that is in tension with different strands of bioethics (e.g., casuistry, feminist ethics, narrative ethics) that are committed to considering the context of ethical issues (Wolf 1994).
On the one hand, a number of authors have identified what they view as problems stemming from these speculative activities of bioethicists, broadly construed, which include neuroscientists, legal scholars, social scientists, and ethicists involved in the debate about the non-medical use of stimulants (Outram 2012; Ferrari et al. 2012). First, these critics have claimed that analyses grounded in highly speculative claims may reflect and encourage technological determinism as well as values associated with scientific and technological development. Second, they have posited that authors who speculate have traded their own responsibility to critically examine the values involved in different positions in the debate for a frame of cognitive enhancement built on false assumptions of the safety and effectiveness of enhancers, or the lack thereof. Consequently, scholars taking an anticipatory ethics approach in the cognitive enhancement debate have been criticized for practicing “speculative bioethics,” invoking slippery slopes, and conjuring up hyperbolic or unreasonable scenarios (Henry et al. 2007; Dees 2004; Launis 2010; Fins 2008; Nordmann 2007). Such a misalignment between the reality of scientific and clinical evidence and bioethical discussion negatively impacts the credibility of bioethics. Furthermore, when bioethical discussions are not consistent with scientific developments, the development and uptake of beneficial therapies may be hindered. Irrelevant or overblown bioethical debates also consume time better devoted to more pressing and ethically difficult matters. Finally, critics fear that ethicists engaged in speculation may encourage the public to adopt an uncritical approach, for example, through the favorable and overly sensational media coverage cognitive enhancement has garnered (Racine and Forlini 2010a, b; Wade et al., paper under review). Unduly optimistic speculation may also present the risk of arousing unrealistic or extraordinary expectations among different stakeholders, which have material implications (i.e., the potential “squandering” of finite resources on a technology or an issue that does not exist). Thus criticisms of speculation may apply to those favoring cognitive enhancement, as well as to critics of cognitive enhancement.
On the other hand, some degree of speculation is worthwhile because it enables the foresight of ethical problems before a novel technology is introduced or disseminated. In this sense, the practice of attempting to forewarn by anticipating future scenarios may be valuable. Roache (2008) claims that speculating about remote scenarios may help guide ethical reflection rather than detract from it. Nonetheless, critics of anticipatory bioethics worry that the identification of ultimately illusory ethical pitfalls will dissuade researchers and investors from developing important new treatments for real health problems (Henry et al. 2007). There is perhaps also a risk of inaction in failing to anticipate and resolve ethical concerns while waiting for certainty or scientific consensus (Kolber 2008). Jones et al. write a propos that, “[t]he challenge for bioethicists is to determine whether they should devote their attention to such extreme speculative possibilities, or to more circumscribed speculations, or indeed whether it is better to focus on existing issues, rather than those that are merely possible” (Jones et al. 2011).
The language and conceptual frameworks used to describe speculation embody normative positions that may influence bioethical analysis. The act of predicting potential outcomes can be captured with different nuances under the labels of “forecasting”, “foreshadowing”, “envisioning”, “imagining”, “anticipating”, “predicting”, and more explicitly “thought-experimenting”, “promising” (Fortun 2005), “hypothetical possibilities”, “speculative scenarios” (Roache 2008), and more negatively, “wishful thinking” (Oakley and Cocking 2005) and “scaremongering” (Carter et al. 2009). Accordingly, different normative perspectives have been presented in the literature with respect to speculation and its strengths and weaknesses based on specific understandings of the role of bioethics and bioethicists in relationship to “emerging” areas of science and technology. In the specific case of cognitive enhancement, some contend that the debate is based on “false assumptions” (Heinz et al. 2012). This view raises the concern that distorted evidence has clouded the understanding of the concrete aspects of potentially harmful practices underlying performance enhancement (e.g., non-medical use of stimulants or do-it-yourself brain stimulation) and obfuscated the need for genuine ethical and critical reflection.
Contrasting views on “speculation” in bioethics
Scope and strengths
Future-oriented speculation is a form of claim-making about the future based on unverified, unverifiable or unknown social, empirical, and scientific knowledge.
Speculation is an important and necessary part of ethical thinking (Roache 2008)
Identifies and extrapolates from generic qualities or attributes of a new technology or development that are likely to present ethical challenges in all or future applications (Brey 2012)
Speculation helps map potential future ethical scenarios, helps to reveal contemporary intuitions and social values at the juncture of the individual, society, and science, and it allows for ethical issues to be addressed from the position of “what really matters” (Roache 2008)
Since speculation involves an imaginative forecasting of different future scenarios, it is impossible to account for all potential users, scenarios, applications, etc. (Brey 2012), which raises the risk of overestimating and underestimating the probability of certain scenarios and raises the further question of which scenarios are worth considering and which are not (Roache, 2008). The activity of speculation can degenerate into speculative philosophy where ethical thinking is “adrift” in science fiction and as a result fails to guide ethical thinking and properly map ethical problems (Jones 2008)
A proactive approach to emerging technologies that yields ethical analysis based on incomplete scientific and social knowledge and that examines their anticipated impact on an uncertain future
Early ethical intervention at the early stages of design and application of new emerging technologies can help guide the trajectory of new technologies and help prevent ethical problems from emerging (Brey 2012)
Solely focusing ethical analysis on the development, use, and application of new neurotechnologies may fail to take into account the social history of neuroscience and neuroethics that have shaped these technologies (Vrecko 2010)
Scaremongering is often associated with, but not necessary to, anticipatory analysis (Hedgecoe 2010)
Anticipatory analysis rests on a “problem of uncertainty” in which ethical issues relating to the use of new technologies cannot be known with certainty or reliability (Brey 2012)
Grounded speculation serves the purpose of predicting scientific advances and thinking about their social or ethical implications but is limited and constrained by a clear knowledge basis and self-reflexivity
Grounded speculation can constrain speculative reasoning by scientific and social science knowledge
Uses forecasting and predictive knowledge
Ensures that the hypothetical nature of scenarios is underscored
Grounding ethical speculation and debate in scientific evidence means debating issues that arise from within the domain of scientific reason and thereby formulating ethical issues and analysis on what is deemed possible by science and society (Roache 2008). Anticipating adverse consequences of emerging technologies risks amplifying unlikely scenarios and improbable effects of those technologies, and “squandering” scarce resources away from more plausible situations (Jones et al. 2011)a
“Wishful Thinking” and “Scaremongering”
Ethical analysis based on speculation or anticipation overstates the potential of neuroscience and neurotechnologies to cure or curb problems ranging from medical disorders to social issues
“Wishful thinking” (Oakley and Cocking 2005) or “scaremongering” characterizes ethical analysis which fuels fears or unrealistic expectations about future scientific advances (Carter et al. 2009). Argumentative structure relies on a “foreshortening of the conditional” in which the “if” of a conditional becomes subsumed by the “then” (Nordmann 2007) and additional logical fallacies include reductionism, straw-man arguments, and slippery slope arguments (Oakley and Cocking 2005)
Mischaracterization of the limits of science based on a specious view of the power of neuroscience and consequently bases speculation on a mistaken projection of the evolution and social consequences of these technologies (Vrecko 2010). This may include the thesis of an inevitable future, i.e., that the future is ineluctably given and cannot be shaped (Outram 2010a)
An overly critical stance on speculative activity and the role of anticipation could limit the ability to foresee upcoming ethical challenges associated with science and technology
The case of pharmaceutical cognitive enhancement is particularly useful for drawing out how speculation about science and technology (Table 1) intersects with contemporary bioethics. The drugs contending for the status of “cognitive enhancer” such as stimulants (e.g., methylphenidate, dextroamphetamines) or acetylcholinesterase inhibitors (e.g., donepezil) are already available and commonly used and prescribed by physicians. These medications are widely accepted internationally by health agencies as effective for the treatment of disorders (Wolraich et al. 2011). The beneficial clinical effects of these drugs have been documented in clinical trials published in peer reviewed literature albeit the understanding of their pharmacological mechanisms of action is incomplete (Iversen 2006). In some cases, initial studies of their efficacy to enhance cognitive performance have been published (e.g., for meta-analyses of methylphenidate studies (Repantis et al. 2010a) and for donepezil studies (Repantis et al. 2010b) but typically in small samples tested in artificial settings, and without the benefit of double-blind randomized controlled trials (de Jongh et al. 2008). Prevalence of use for enhancement has been documented mostly for stimulants, often indirectly through broader surveys of “recreational uses” and typically in populations of limited representativeness (e.g., specific North American college campuses). Hence, the case of pharmacological cognitive enhancement offers a mixture of existing and available technology but discussed in a context marked by an absence of clear and convincing evidence about efficacy and prevalence of enhancement. The case of cognitive enhancement is therefore a particularly interesting example on which to base a critical appraisal of speculation. It reflects a set of possible circumstances and social goals while moving away from the purity of theoretical ideal-types (Table 1) to bring attention to specific attributes of scientific and social contexts. In fact, the complexity of the debate on cognitive enhancement has given rise to a series of assumptions, which we review briefly, related to: (1) terminology; (2) scientific aspects; (3) sociological aspects; and (4) normative aspects.
Assumptions about terminology and normative frameworks used to describe the non-medical use of stimulants
The terminology, definitions, and normative frameworks used in bioethical discussions of cognitive enhancement have carried diverse connotations, sometimes treating the meaning of enhancement as self-evident and therefore leaving it undefined. The diverse terminology has potentially contributed to a mischaracterization of the non-medical use of stimulants. For example, the terms “neuroenhancement,” “smart pills”, and “cognitive enhancers” (Racine and Forlini 2010a, b) may poorly translate the factual aspects of these practices and the normative features they implicitly carry. The term “cognitive enhancement,” suggests that certain pharmaceutical substances work to enhance cognitive capacities generally and without any tradeoffs (Racine and Forlini 2010a, b; Hall and Lucke 2010). The term also suggests the potential accomplishment of a singular personal and social goal, namely to “enhance” or “become smarter”. These enthusiastic characterizations of pharmaceutical substances and social practices could inadvertently influence ethical thinking (Outram 2012), perpetuate or exacerbate misperceptions of the practices and motivations, lead people to overestimate the prevalence of the non-medical use of stimulants (Ferrari et al. 2012; Lucke et al. 2011) and create ethical blind spots where misleading factual assumptions encourage an uncritical stance (Racine and Forlini 2010a, b). Some have contended that this portrayal of cognitive enhancement can create forms of coercion in academic (e.g., peer pressure created by the use of cognitive enhancers by fellow students) and professional environments (e.g., pressure created by the use of cognitive enhancers by colleagues, or explicit pressures of supervisors to use enhancers) to perform at higher levels (Ferrari et al. 2012; Outram 2012). Evidence from stakeholder research suggests that the terminology and frames used to describe cognitive enhancement could indeed have the consequence of inducing fatalism and social acceptance of unproven practices (Forlini and Racine 2009a, b; Forlini and Racine 2012; Wade et al., paper under review).2
Assumptions about scientific aspects such as efficacy and safety of the non-medical use of stimulants
Several implicit assumptions about scientific aspects of cognitive enhancement have been propagated in the literature despite the lack of supportive empirical evidence. For example, it is widely assumed that certain pharmaceutical substances optimize cognition (e.g., focus, concentration, memory, and alertness) and that their use is safe. Even among authors who acknowledge this lack of evidence, there exists an assumption that evidence supporting their efficacy and safety will eventually emerge if the right studies can be done (Boot et al. 2011). Claims about the safety and efficacy of stimulants in healthy individuals have been partly constructed on the assumption that these substances can improve cognitive performance in healthy individuals just as they may do in cognitively impaired individuals (Outram 2010b; Boot et al. 2011). However, this generalization is problematic since the investigation of pharmaceuticals in the context of illness cannot be generalized to non-medical use of stimulants in healthy individuals (Repantis et al. 2008, 2010a, b; Lucke et al. 2011). Further, there are limitations to what existing study designs can tell us about the efficacy and safety of the non-medical use of stimulants because of the challenges of measuring, assessing, and substantiating the efficacy of cognitive enhancement in the absence of standardized tests for enhancement effects (Lucke et al. 2011). For example, claims about the effect of donepezil on a handful of aircraft pilots have been heralded in the media and throughout bioethics discourse as evidence of the cognitive enhancement effect of donepezil in healthy individuals (Wade et al., paper under review) in spite of explicit claims from the original authors of the study to the contrary (Connemann 2003). Moreover, it is difficult to know whether reports suggesting the efficacy of performance enhancers include individuals who are self-medicating an existing undiagnosed condition (Lucke et al. 2011; Outram 2012). Finally, distinguishing enhancement effects from potential placebo effects is difficult since user expectations and confidence might increase cognitive capacities (Hall and Lucke 2010) or elevate mood (Lucke et al. 2012). One serious but underappreciated safety issue in this debate is the overall addictive potential of stimulants (Heinz et al. 2012; Lucke et al. 2011; Ferrari et al. 2012), since these “substances necessarily modulate systems relevant for learning and memory also implicated in drug addiction” (Heinz et al. 2012). Speculative discussions about cognitive enhancement have ignored potentially serious safety and efficacy concerns, sometimes even explicitly assuming complete safety and effectiveness. The value of such speculation is questionable if the underlying assumptions are invalid.
Sociological assumptions about prevalence and normalization
The literature on the non-medical use of prescription stimulants frequently contains assumptions about the prevalence of their use as well as increasing demand for stimulants (Mohamed and Sahakian 2012). As well, assumptions concerning moral acceptability, social desirability, and praiseworthiness of cognitive enhancement have, in turn, contributed to normalizing the issue (Ferrari et al. 2012; Heinz et al. 2012; Lucke et al. 2011). Lucke et al. (2011) identified at least three significant weaknesses of claims that draw on studies about the widespread prevalence of stimulant use. First, surveys conflate non-medical use and abuse with use for the purpose of enhancement, thereby failing to differentiate between the different ends towards which stimulant drugs are used (e.g., undiagnosed ADHD). Second, the studies cited do not support claims about the widespread use of enhancement practices. Finally, the results of surveys are not always accurately reported in the current cognitive enhancement literature. Lucke et al. (2011) suggest that the lack of information on the prevalence of non-medical uses of stimulants requires that studies continue to examine and document the motivations surrounding such behavior before making conclusions about the prevalence of cognitive enhancement practices.
Concomitant with the assumption that cognitive enhancement is a widespread practice are the assumptions of the social acceptability of taking medications without a prescription and the moral praiseworthiness attributed to the act of enhancement (Racine 2010). By overestimating or exaggerating the extent to which enhancement is undertaken, bioethical discussions could have implicitly contributed to the argument that it is socially acceptable because it is inevitable. Such an argument clearly overextends what is known about non-prescription stimulant use with respect to its moral acceptability, praiseworthiness, and social desirability. In fact, the presumption may conflict with the little we do know, specifically students’ ambivalence about taking stimulants for the purposes of enhancement (Forlini and Racine 2012; Franke et al. 2012). The impact of erroneous claims about prevalence is not unidirectional; overestimates may also prompt overly negative reactions while underestimates could lead to lack of due attention to the issue. Again here, unchecked assumptions about prevalence and normalization, have percolated into the debate and into the arguments of some leading authors.
Normative assumptions about the need for ethical reflection in the form of a “preparatory” or “anticipatory ethics” and the call for regulatory guidelines
One final set of assumptions within bioethical discussions on cognitive enhancement is the need for an “anticipatory ethics,” “prospective ethics”, “preparatory” or “upstream” ethics (Am 2011) and the need for regulatory guidelines to respond to and manage requests by healthy individuals for cognitive enhancement (Larriviere et al. 2009). This claim, identified in the literature as well as policy discussions (Outram and Racine, 2011a, b), can be boiled down to the call for a “prospective ethics in order to avoid a gap occurring between ethical reflection…and the state of the art in research and development” (Ferrari et al. 2012). Some bioethical discussions indicate that expectations surrounding the demand for cognitive enhancement have set in motion policy discussions and regulatory guidelines to help align social norms with public policy (Farah 2011; Greely et al. 2008). However, if neither the scientific nor sociological claims about cognitive enhancement practices are substantiated by clear evidence, the need to manage individual requests through “prospective ethics” and guiding regulatory frameworks can be called into question (Ferrari et al. 2012). Lucke et al. (2011) have captured the problem of unrealistic or exaggerated expectations under what they call the “neuroenhancement bubble”, i.e., the effect of the exaggeration of certain claims, the distortion of empirical evidence, and the overall uncritical ethical analysis about cognitive enhancement. Obviously the relationship between the nature of a scientific advance or a new health practice and the need for anticipatory ethics is complex; the cognitive enhancement debate cannot be dismissed as misdirected ethics scholarship. However, this complexity has often gone unacknowledged with some sweeping claims that increasing or high prevalence necessarily calls for proactive ethics discussion (with the equally debatable corollary assumption that low prevalence would be a sufficient condition to dismiss the debate).
In the next section, we discuss how the different assumptions could be better acknowledged in the cognitive enhancement debate, and perhaps in other areas of bioethics, in order to avoid some of the possible negative pitfalls of speculation and to capitalize on the value of proactive ethical approaches.
Methodological guideposts for informed and reflexive speculation in bioethics
Acknowledge assumptions more explicitly and identify the value attributed to them
Speculation in ethics can be a very valuable tool. However, the case of the non-medical use of stimulants shows that ethicists, legal scholars and others could better identify the assumptions or “hypotheticals” which have a determining impact on the normative stances taken. To borrow the language of casuistry (Jonsen 1995), notions such as efficacy, prevalence, or social harms can amount to “circumstances” that “make the case” of cognitive enhancement. Perhaps of greater importance is the need to recognize that these circumstances are in some cases true variables or hypotheticals, in the sense that different values can be assigned to them and these values shape the global appreciation of what is at stake and what is determined to be the proper response. The use of assumptions and hypotheticals is well accepted in other domains of knowledge which involve modeling decision-making and choices. Economists, for example, using different models, do not shy away from predictions about economic growth, unemployment rates, or inflation but they are also asked to make explicit the assumptions (or parameters) underlying their models and their impact on the resulting predictions. These assumptions can easily be overlooked but at very least, they can be traced back, discussed, criticized, and revised. To neglect or dismiss these underlying assumptions can lead to significant harms and misses the opportunity of analyzing them from an ethical standpoint (Colander et al. 2009). Economists likely have more conceptual and mathematical tools at their disposal than bioethicists to pinpoint the assumptions they are making and their impact on their scholarship. Given the amorphous and implicit packaging of assumptions in bioethics, attempts to make them clear and explicit would furnish useful precedents that could help bioethics achieve additional rigor particularly in relation to the use of assumptions within speculation and modeling. An initial step could simply consist in stating explicitly the assumptions (e.g., about efficacy, prevalence) as well as the importance (or value) assigned to them in the global ethical evaluation of cognitive enhancement. Such clarifications would help distinguish disagreement about underlying factual assumptions from disagreements about their normative evaluation. Thus, disagreements could be better circumscribed and their possible resolution better defined for further specific inquiry. Avenues for further methodological progress informed by other disciplines could be explored to build more integrative and transparent use of assumptions in bioethics scholarship.
Validate assumptions with interdisciplinary literature
Acknowledging the existence of assumptions is a first step but we have also demonstrated that some assumptions in the bioethics debate about cognitive enhancement have lacked a sound empirical basis. Statements about prevalence have been exaggerated and likewise claims about efficacy have been reported inaccurately. Ferrari et al. (2012) observe that “ignorance of the empirical literature creates a bias effect when it comes to formulating relevant ethical questions”. They state that “an improper account of empirical data obtained in both experimental pharmacological research and the social sciences restricts the narrative framework within which the visions of pharmacological cognitive enhancement are conceptualized, because it reifies it as an entity despite the lack of evidence” (emphasis in the original). Moreover, it functions to collapse a complex sometimes contradictory phenomenon into a single framework of understanding, i.e., “cognitive enhancement” (Outram 2012). A related recommendation in the literature is “caution and skepticism” regarding scientific and sociological claims about cognitive enhancement practices and in adopting the associated policy proposals and guidelines (Hall and Lucke 2010; Lucke et al. 2012; Outram 2012; Racine and Forlini 2010). Hall and Lucke (2010) have argued that “[m]ore skepticism needs to be expressed about neuroenhancement claims for pharmaceuticals and bioethicists should be much more cautious in normalizing such use by inflating estimates of its prevalence or making proposals that will facilitate such use”. Similarly, Outram suggests exercising “cautious skepticism as to the future implications of this practice” to avoid reification, misperceptions, and hyperbole (Outram 2012). The validation of assumptions about scientific aspects of cognitive enhancement could have been pursued with greater energy and commitment through the use of evidence from different empirical disciplines and the adoption of higher standards of rigor in searching for such evidence. These are directly identifiable constraints to introduce within ethics reflection about science and technology. In situations where factual claims are hard to establish, intellectual honesty would nevertheless call for clear and explicit acknowledgment of the gaps.
Generally speaking, bioethics scholarship has long stressed the need for sound factual claims in areas such as clinical ethics and research ethics (Jonsen et al. 1998; Beauchamp and Childress 2009). The use of empirical research and the commitment to understanding factual aspects of ethical situations has been claimed to be a trademark of bioethics scholarship in comparison to other approaches (Toulmin 1982; Racine 2008). Some approaches in clinical ethics like casuistry have made of this a formal first step of ethical analysis (Jonsen et al. 1998). However, ethical analyses in themselves, and any resolution or action proposed by an ethical analysis, may involve unknowns in terms of medical, legal, societal or ethical outcomes. The challenge of predicting outcomes differs greatly between the analysis of a clinical case (e.g., outcomes and consequences of withdrawal of life support from the point of view of clinicians and family members) and the prediction of outcomes in a whole area of technological development (e.g., pharmacological cognitive enhancers) because of the vastly different scales of assumptions and consequences involved. A clinical case may represent a micro-context with great complexity but nevertheless some immediately identifiable implications, with direct consequences for individuals. But the nature of the assumptions and unknowns involved in discussing the macro-context of the nascent phenomenon of cognitive enhancement (e.g., prevalence, safety, efficacy, social acceptance) increase the challenge of generating factual evidence to support the claims and to inform transparently the normative stances taken. Perhaps closest to the goal of anticipatory ethics and proactive ethical approaches is the field of health technology assessment where the ethical assessment of the impact of a technology is undertaken. At this time, a few methodological approaches have been proposed within this field but they still fall short of reconciling the full complexity of ethical analysis and its complex relationship to factual assumptions (Van der Wilt et al. 2000). Further theoretical and normative work could tease apart when and to which extent, bioethicists should be expected to validate factual claims implied in ethical analyses (e.g., carrying empirical research themselves or relying on other researchers’ work) and how they could do so (e.g., consult primary literature or review papers; report explicitly the level of evidence supporting different factual claims).
Adopt a broad perspective to support more comprehensive reflection
Several problematic assumptions in the cognitive enhancement debate point to a lack of perspective beyond contemporary societal and cultural contexts or preferred ethical stances. A reflexive examination can be deployed as a corrective to reveal and address latent biases, misguided assumptions and gaps in the process of making certain claims within the literature. Thus, reflexive practices introduce the concept of an “ethics of doing ethics” because, as a practice, they can correct biases and suggest questions about ethics itself. We point to and discuss three relevant approaches potentially supporting a more reflexive practice of bioethics.
Compare disciplinary frameworks
Although it has been suggested that the ethical discussion of the non-medical use of stimulants is “reinventing the bioethics wheel” (Parens and Johnston 2007) by those active in early discussions about human genetic enhancement, the case of cognitive enhancement shows that there can be challenges when a phenomenon is uncritically captured under an umbrella term like “enhancement,” which may carry assumptions from earlier bioethical debates about other forms of enhancement. For example, the data showing how “cognitive enhancement” became a dominant frame in the bioethics literature point to a problematic situation where other disciplines and perspectives (e.g., public health) were inadequately taken into account (Forlini and Racine 2009a, b; Wade et al., paper under review). In the epidemiological and public health literature, more critical perspectives emphasized other concerns such as addiction and public harm. This contrast between public health and bioethics frameworks shows the value of moving bioethics reflection away from its own disciplinary comfort zones to consider the perspectives of other fields or disciplines. Some bioethics discussions were committed to an implicit “frame of reference,” which defined the issues and nature of the topic and limited the discussion and range of issues and solutions to be explored. Hence, more explicit effort to research or imagine other frames of references could be valuable to avoid biases in ethics reflection (Racine and Forlini, 2010a, b). As Outram (2012) suggests, “if we are to take into account the different frames by which to understand the non-medical use of stimulants, we should adjust our ethical concerns accordingly”. The current enthusiastic framing of cognitive enhancement may align with a technoscientific agenda and could inappropriately constrain the discussion. Overall, a general mindfulness of the language in ethical discussion of cognitive enhancement (e.g., terms, frameworks) might help avoid some early biases.
Consider historical knowledge
Looking at precedent social trends, events, and scholarship can generally assist self-reflection (Racine and Illes 2006). Relevant to the case of the enhancement use of stimulants, previous work from Andrea Tone (2005) has shown that anxiolytics (meprobomate in the 1950s and benzodiazepines in the 1960s, 1970s, and 1980s) were used widely for lifestyle purposes. Tone has invited further reflection on how social context can shape new therapeutic paradigms in psychiatry and, consequently, the need to take into account a broad range of historical factors. By challenging the suggestion of novelty implicit in the term “neuroenhancement,” Bell et al. (2012) highlight the lack of historical perspective in bioethical discussions, and the narrowness of bioethical perspectives that do not consider the cycles of enthusiasm for drug use for enhancement purposes throughout history. Lucke et al. (2011) similarly situate the practice of cognitive enhancement within a historical context: “[t]he use of stimulant drugs to enhance human functioning is not a new phenomenon but arguably a recent manifestation of a common cycle of enthusiasm and disillusionment with the enhancement use of drugs with stimulant effects”.
Consulting the archives of the history of medicine, specifically examining pharmacology and trends in treatments could help ethical reflection to be more sensitive to social factors that shape our ethical thinking about pharmacological stimulants and other technologies. For example, a historical perspective might shed light on the social and cultural expectations surrounding technology and bring additional insights to constrain speculation about the present issue of cognitive enhancement, notably the impact of social acceptance and normalization on ethical analyses and resulting stances (Lucke et al. 2012). A related recommendation would be to make explicit social and temporal contexts in which assumptions may be valid (Ragan et al. 2013). In the case of the debate on cognitive enhancement, the North American context of the initial prevalence studies and the impact of this context on the ensuing normative debate has often gone silent (Forlini and Racine 2009a, b). Other societal and cultural contexts could bring forth different ways of manifesting and responding to “cognitive enhancement”. To remedy the fundamental biases related to context, contributors to the debate would need to recognize that they themselves “are part of a specific culture and a specific society at a concrete point of time in history. They also cannot break out of the present, always shaping the futures they tell us about on the basis of present knowledge, present estimates of relevance, present values and present worldviews” (Ferrari et al. 2012). This would recognize the profound embedding of ethical approaches in social context and its impact on constitutive features of human psychology, including ethical analyses (Dewey 1922).
Reflect on the development of normative approaches
Clearly, normative approaches to the non-medical use of stimulants do not emerge by themselves but are an outcome of an evolving and active process of thinking and analysis. The task of ethics is partly to innovate and develop normative approaches to contemporary challenges (Illes and Racine 2005). However, the immediate nature of the task of bioethics can sometimes discount the implicit biases or assumptions that can be carried forward as well as the contingent and contextual nature of theoretical approaches (Zoloth 2007), which have been described as “lenses” by some feminist bioethics scholars (Sherwin 1999). Recently, a shift from questions of the moral acceptability of stimulant use to an examination of the social desirability of enhancement has been identified (Ferrari et al. 2012). Ferrari et al. call for an assessment of underlying visions, noting that “[t]his implies distancing oneself from the actual existence of certain desires in society and asking which desires are based on good motives and how they are attached to particular technological visions. Any genuine ethical reflection on HE [human enhancement] technologies should explicitly acknowledge that it constitutes discourse on visions of technological development, rather than concentrating on the novelty of ethical conflicts raised by these visions” (Ferrari et al. 2012).
We might address problems of myopia and complacency in ethical analysis by changing our assessments to consider how norms are built into our framework of understanding non-medical uses of stimulants at specific times and spaces. Thus oscillating between different theoretical lenses could generate a more comprehensive vision. In the case at hand, it would become clearer that, “visions do not exist per se, they are not discovered and they do not arise of their own accord; they are “made’” since they are “deeply related to our attitudes, knowledge, perceptions, values, world views and interests of their authors and disseminators” (Ferrari et al. 2012). Reflection on one’s normative stance is intimately linked to self-reflection and an assessment of one’s own biases and social positioning (Racine and Illes 2006) and can thus help bioethicists take a more reflexive stance in debates.
In the context of cognitive enhancement, where there have been clear tensions between different normative positions (notably between liberally-minded and more conservatively-minded bioethics in the American context) (Racine 2010), a few proposals have been put forward to enrich theoretical lenses. These proposals have ranged from recognizing the mutual terrain between opposed normative frameworks or approaches (Parens 2005; Racine 2010) to the call for moral creativity beyond the battle lines drawn by bioethics advocacy (Racine 2010). Parens has proposed a dialogue between the creativity framework (organized around the concept of self-transformation) and the gratitude framework (organized around the concept of lettings things be). He recommends acknowledging the deeper assumptions (e.g., about human nature and technology) underlying these frameworks and recognizing how single individuals may adhere to both frameworks (Parens 2005; Racine 2010). Racine has proposed that different ethical evaluation criteria can be derived from opposed normative stances, i.e., criteria of moral acceptability from liberal positions and criteria of moral praiseworthiness form conservative positions. These stances can then be combined to yield a more comprehensive normative approach (moderate liberalism) which builds on both positions (Racine 2010). These two contributions by Parens and Racine are steps in the direction of establishing broader reflexive standpoints based on sometimes opposing normative views.
Although we have identified challenges in the use of speculation in the cognitive enhancement debate, this paper should not be interpreted as a dismissal of the contribution of speculation in ethical thinking, but rather a framework to enhance the relevance and quality of scholarship featuring speculation. Speculation is an important part of ethical and philosophical thinking and can yield valuable insight by helping to expose socio-cultural values and help refocus our ethical thinking on “maximizing what is most valuable” (Roache 2008). Speculation is also a strategy to reduce technological determinism, by allowing ethical thinking and response ahead of rather than at the heels of emerging technologies. Speculative scenarios, when they are understood as such, can yield insight into the present and the future. In the context of our case study on cognitive enhancement, most critiques of speculation have not been wholesale arguments against the essence of anticipatory ethics or speculation as such. Rather, specific assumptions have been identified where further objective analysis is possible. For example, prevalence has been widely described as “increasing,” including by one of the authors of this paper (Racine 2010), although closer subsequent examination of data showed conflicting perspectives. Repeated and publically disseminated claims about matters such as efficacy and safety are not benign. Bioethicists and those involved in ethics debates become part of a social construction process in which their claims contribute to shaping and inflating expectations of the general public as well as stakeholders like professional societies and governmental agencies. “The media repetition of claims about stimulant use has amplified the perceived extent of their use beyond that which is indicated by closer examination of the survey evidence” (Lucke et al. 2011). Hence it is clear that a model of “constrained speculation” (see Table 1) represents a promising middle-ground approach. However, in hindsight, debatable assumptions appear clearly in the discussion of cognitive performance enhancers, but what is most challenging for the ethics community, and perhaps more useful, is how to explicitly identify and consider assumptions early in bioethics discussions and within clearer methodological guidelines. In this paper, we have identified methodological suggestions that should be further defined and explicitly employed.
There are some limitations to the approaches we propose in this paper. First, the authors are from Commonwealth countries (Canada and Australia) and represent limited diversity in terms of cultural background. Second, we have explored how speculation could be constrained and certain types of assumptions be made more explicit but we realize that more work and deliberation is needed in this area and consider our paper to only provide some preliminary reflections. Third, we have left aside for the purpose of this paper the role that the media and other stakeholders have played in the proliferation of assumptions about cognitive enhancement (Forlini and Racine 2009a, b; Boot et al. 2011; Partridge et al. 2011). We also did not focus on the sociological or historical reasons why some of the assumptions about the cognitive enhancement debate have made their way into the academic debate. There are a range of alternative hypotheses which have not been explored in this paper but may provide fruitful avenues of enquiry. These may include the “incentive structure” relating to the career progression of scholars (e.g., bioethicists being rewarded by recognition following media attention, or achieving grant funding for issues perceived to be of importance). Contributors to the debate about cognitive enhancement may also lack formal bioethics training which then leads to a less critical or scholarly treatment of the ethical issues that may be involved. Another consideration is the tendency of journals to publish papers which are considered to be important, leading to the temptation to overstate the significance of issues. The investigation of these hypotheses would require distinct research methodologies based on what has been attempted in other areas of bioethics (Evans 2002).
In this paper, we have described the controversy over the non-medical use of prescription drugs and underscored how this case opened up the floor for reflection on the nature of bioethics scholarship and the “ethics of doing ethics” about emerging areas of science and technology. The case of non-medical use of prescription stimulant is relevant because of the availability of the technology (existing neuropharmaceuticals) and the discourse surrounding its repurposing as a cognitive performance enhancer. We identified, based on previous literature, distinctive sets of assumptions with respect to terminology and framing, scientific aspects of the non-medical use of stimulants, sociological assumptions as well as assumptions about normative approaches. This context set the stage for a discussion of how speculation about the non-medical use of stimulants and science and technology could be better informed. We proposed a number of methodological procedures such as: (1) acknowledging assumptions more explicitly; (2) validating assumptions with interdisciplinary literature; and (3) taking a broad perspective to support more comprehensive reflection. We acknowledge our own reflection to be shaped by our research goals and previous contributions and call for greater awareness and willingness of the community of scholars engaged in bioethics scholarship to partake in exchanges on this topic.
Our own reflection was part of a project examining the legal, ethical and social consequences of memory technologies in an effort to engage in meta-ethical questions about bioethics itself. Some of the authors of this paper have directly intervened in this debate and therefore take a reflexive stance on their own scholarship and the claims made in their contributions.
Throughout debates about the non-medical use of stimulants, a further complicating factor has been the evolving definition of the term “cognitive enhancement”. Ferrari et al. (2012) identify these shifts in meaning by looking at the history of human enhancement: “the term ‘cognitive enhancement’ was originally used to describe the treatment of disease-associated cognitive impairment…the meaning of the term was subsequently broadened to encompass the use of interventions for mild cognitive impairment (MCI) (…) More recently ‘cognitive enhancement’ has been applied to interventions in normal ageing processes and in ‘healthy’ people for non-medical purposes” (Ferrari et al. 2012).
Support for this work comes from a catalyst grant of the Canadian Institutes of Health Research (CIHR; Jennifer Chandler, PI; Eric Racine co-PI), a University of Queensland Travel Award for International Collaborative Research (Jayne Lucke), the Canadian Institutes of Health Research (New Investigator Award, Eric Racine) as well as the Fonds de recherche du Québec—Santé (Career Award, Eric Racine). We extend our thanks to members of the Neuroethics Research Unit for feedback on a previous version of this manuscript and to Ms. Allison Yan and Mr. John Aspler for editorial support. Thanks to Brad Partridge who was a visiting researcher at the Neuroethics Research Unit in 2012 for feedback on the concept of this paper. Thanks also to Dr. Emily Bell and Dr. Veljko Dubljevic for comments on a draft version of this paper.
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