Ethical Considerations in the Framing of the Cognitive Enhancement Debate
Over the past few years the use of stimulants such as methylphenidate and modafinil among the student population has attracted considerable debate in the pages of bioethics journals. Under the rubric of cognitive enhancement, bioethicists have discussed this use of stimulants—along with future technologies of enhancement—and have launched a sometimes forceful debate of such practices. In the following paper, it is argued that even if we focus solely upon current practices, the term cognitive enhancement encompasses a wide range of ethical considerations that can usefully be addressed without the need for speculation. In taking this position it is suggested that we divide cognitive enhancement into a series of empirically-constructed frameworks—medical risks and benefits, self-medication and under-prescription, prescription drug abuse and over-medication, and finally, the intention to cognitively enhance. These are not mutually exclusive frameworks, but provide a way in which to identify the scope of the issue at hand and particular ethical and medical questions that may be relevant to enhancement. By a process of elimination it is suggested that we can indeed talk of cognitive enhancement as an observable set of practices. However, in doing so we should be aware of how academic commentaries and discussion may be seen as both capturing reality and reifying cognitive enhancement as an entity.
KeywordsBioethics Cognitive enhancement Framing Stimulants
Introduction: What is Cognitive Enhancement?
Cognitive enhancement has attracted the attention of many in the bioethics community interested in the societal and individual-level consequences of the new technologies such as deep brain stimulation or new uses of existing technologies such as psychotropic drugs [1, 2, 3, 4, 5, 6]. Conversely, several commentators have argued that bioethics is being led into unwarranted territory with little scientific and sociological empirical evidence to support the underlying claims being made regarding efficacy and usage [7, 8, 9]. In an attempt to redress the balance between future and present contexts, the following paper examines how we might envisage the ethical questions concerned with the use of cognitive enhancements as practiced today. The following paper is thus addressed to the bioethics community involved in this debate and is also addressed to those most involved with cognitive enhancement as practiced—the users of cognitive enhancers (in particular, college students) and the sometimes inadvertent suppliers of cognitive enhancers, namely physicians and neurologists [10, 11, 12]. In summation, cognitive enhancement raises current ethical issues that are worth addressing from an empirically-grounded and practical standpoint even if the underlying theme of this paper is that we might do well to maintain a cautious skepticism as to the future implications of this practice.
Notable commentators on cognitive enhancement Bostrom and Sandberg have stated that “[c]ognitive enhancement may be defined as the amplification or extension of core capacities of the mind through improvement or augmentation of internal or external information processing systems”. Thus, the term could include dietary supplements and nutrition as forms of internal amplification as well as computers, calculators, and potentially even a pen and paper as forms of external processing systems. No doubt some will see the introduction of computers and calculators as controversial due to their possible impact upon mental capacities, but such discussions have largely been bypassed through familiarity. As Bostrom and Sandberg point out “[e]ducation and training, as well as the use of external information processing devices, may be labeled as “conventional” means of enhancing cognition. They are often well established and culturally accepted” . By contrast, much of the discussion in the pages of bioethics journals focuses upon the use of medical technologies by healthy individuals. For example, in discussing the use of mixed amphetamine salts (Adderall), Farah et al. centre their discussion on “[t]he use of stimulant medication for cognitive enhancement by healthy individuals” , while Sahakian and Morein-Zamir refer to how drugs used in the treatment of cognitive disabilities are being used to “improve performance on cognitive tasks in healthy individuals”. Thus we should remind ourselves that cognitive enhancement encompasses a wide range of activities—from the conventional to the unconventional. Furthermore, in constructing cognitive enhancement as a point of ethical concern, the bioethics community should remind it that this ethical discussion of cognitive enhancement is not reflective of the entirety of cognitive enhancement itself (which has a considerably wider contemporary context and could arguably be seen as something that is ubiquitous in human history).
The reason for highlighting this point is that as a first step towards this process of grounding discussions of cognitive enhancement we must firstly tackle the thorny issue of what the term constitutes. In doing so, it is suggested that we have several potential options by which to understand this term; but not unsurprisingly it is the use of medical technologies by healthy individuals that is the focus of bioethics attention—not the widely accepted and practiced use of calculators, formal and informal education, and the impact of nutrition on the brain. This does not imply the focus of the discussion is wrong, simply that in making particular choices we frame such debates to suit a purpose, sometimes without recognizing the impact this framing has on the wider understanding of such terms. As this paper continues, different frameworks are offered by which we might envisage cognitive enhancement. It is suggested that within each we might wish to revise our understanding of how we discuss this issue as practiced and the ethical and/or pragmatic questions that emerge from these frameworks.
What Forms of Cognitive Enhancement are Practiced and by How Many People?
It has been suggested that use of cognitive enhancers—as discussed in bioethics literature—involve some form of medical technologies and novel ways of using such technologies. This could include novel neurological technologies that are largely experimental, such as deep brain stimulation and transmagnetic stimulation or relatively old pharmacological technologies (stimulants) used in a novel manner. At this point we can further subdivide how cognitive enhancement is practiced currently from its potential future. With respect to deep brain stimulation and transmagnetic stimulation, we have little or no empirical evidence of anything that could be called a widespread use of these technologies by members of the public wanting to enhance their abilities. Indeed, the British Medical Association report on cognitive enhancement has highlighted, such technology is largely experimental and it is “highly questionable whether healthy people would want, or should be encouraged to want, to have invasive brain surgery, with all its attendant risks, in order to enhance their cognitive ability” . Similarly with respect to transmagnetic stimulation, the report states “[a]lthough research has identified some small, short-lived, task specific improvements in a laboratory setting, this is very different from the significant, long-term, useful improvements that would be required to justify its use in real-life settings and on a population basis” . Without scientific evidence of their (non-theoretical) efficacy and sociological or medical records to suggest that healthy individuals are using either of these technologies to augment their brain capacities (or alter mood, memory etc.) on a scale that would be significant at a societal level, we can largely discount these practices if we want to ascertain the scale of cognitive enhancement as currently practiced. Instead, if we want to explore current cognitive enhancement practices (and the most likely form of practice in the short to medium term) we must focus upon the use of pharmaceuticals, especially stimulants.
By contrast to these experimental forms of cognitive enhancement, an increasing number of studies have now documented the use of stimulants without a prescription (also referred to as the non-medical use of stimulants) within colleges and universities (potentially for the purposes of cognitive enhancement) [15, 16, 17, 18, 19]. By way of summary a rough estimate of lifetime usage of stimulants without medical prescription among college students might be between 8-25% of the population, with an annual use between 4–10%, with monthly use around half of this, and weekly around half again. Such figures are not so much disputed, but are subject to considerable variation according the methodology used to collect the information and the difficulty of collecting accurate data when such practices are illegal (although rarely prosecuted).
Several important situational caveats may be added regarding the scale of this non-medical use of stimulants. The first is that the scale of this use is dwarfed by the use of alcohol (at around 80% annual use) and marijuana (around 30% annual use) with the use of amphetmines (at around 7.5%) but is nevertheless not insignificant in this population group (note figures are for annual use). The second is that a vast majority of studies on students focus upon methylphenidate . This focus appears to be correct in the light of one of the few studies which breaks down this use and found that around 96% of those self-reporting a non-medical use of stimulants specified methylphenidate as their drug of choice . Nevertheless, the focus upon methylphenidate is nevertheless limiting in our understanding of the scale of this issue. A potentially interesting statistical contradication to this focus upon methylphenidate has been found in a prevalence study undertaken by Maher et al. within which a pole of readers of the journal Nature found that of the approximately 20% readers stated that they had used such drugs to enhance, that 62% of users reported taking methylphenidate and 44% reported taking modafinil (an additional 15% said they had taken beta blockers) . Whether this is simply a sampling anomaly, a product of the question being asked about cognitive enhancement rather than drug use, or simply that the readership included more non-students is not known. Thirdly, an important caveat that might be seen a significant for current and future ethical consideration is that of growth in demand. Unfortunately, most studies of college use provide only prevalence data, with no indication of growth or decline. In one of the few comprehensive longitudinal studies, Johnson et al. appear to indicate a downward trend in annual methylphenidate use (along with a downward trend in overall illicit drug use over the period in which it is recorded). The study records that in 2002 methylphenidate use (recorded as Ritalin use) was recorded at 5.7%, following which such use declined steadily, dropping to 3.2% in 2008 and then dropping dramatically to 1.7% in 2009 .
Finally, an additional factor which may be deemed important with respect to the scale of cognitive enhancement is known motivation for use. Again, statistics are variable. On the basis of their study of college students Rabiner et al. deduced that “54% of nonmedical users used ADHD [attention deficit hyperactivity disorder] medication exclusively for academic reasons, 6% used it exclusively for nonacademic reasons, and 40% used it for both academic and nonacademic reasons” . Similarly, the White et al. study of 1025 returned surveys from students of the University of New Hampshire, concluded that improving attention was given as the dominant reason for misuse, with improving studying habits and grades were third and fourth respectively (recreational use/partying was second) . Thus although motivations are weighted towards what might be called cognitive enhancement, we should be wary of assuming that all stimulant use is for this purpose. Notably, in the Barrett et al. study of McGill University in Canada it was reported that “70% of those who used MPH [methylphenidate] reported using it for recreational purposes, while the remaining 30% reported using it exclusively as an aid for study” . The reason for this particularly anomaly (reversing the standard balance between enhancement and recreation) is unknown; and may (along with the Maher study) be the product of peculiarities in sampling technique, survey question asked, or the population studied.
In summary, if we are to argue—as is usually the case in such discussions of cognitive enhancement—that the main empirical evidence we have of such practices is through non-medical stimulant use we have reasonably strong evidence to suggest that such practices exist, although on considerably smaller scale than other forms of non-medical drug use. However, in using these statistics we need to be cautious; although we can be relatively sure that a majority of individuals are using such drugs at least partially for enhancement (study) purposes of some sort, this is by no means an exclusive or necessarily dominant motivation.
Framework One: Risks and Benefits
The first formal framework proposed is to frame this non-medical use of stimulants in terms of attendant medical risks and benefits. These studies have been summarized in Repantis et al. 2010 meta-analysis of 46 studies of methylphenidate and 45 studies on modafinal use in ‘healthy’ individuals . With respect to the risks of methylphenidate, the primary risks appear to include appetite reduction, insomnia, and the potential for anxiety depression [25, 26, 27, 28]. For modafinal, Repantis et al. report that the risks include headache, dizziness, gastrointestinal complains, dry mouth, nervousness, restlessness, and sleep deprivation among others . In addition, Kollins has reported a potential for addiction to methylphenidate . However, while the list of potential side-effects is alarming, it is generally reported that both drugs are well tolerated .
Taking a strict interpretation of risk and benefit, we may wish to contrast these medical risks to the controlled experimental data suggesting the benefits of using such drugs as cognitive enhancers. With respect to what might be called the ability of such drugs to enhance, the conclusions reached by Repantis et al. were as follows, “[w]ith regard to MPH [methylphenidate] we were not able to provide sufficient evidence of positive effects in healthy individuals from objective tests.” With respect to the benefits of modafinal the conclusions of the reviewers are slightly more positive, stating that modafinil was “found to improve attention for well-rested individuals, while maintaining wakefulness, memory and executive functions to a significantly higher degree in sleep deprived individuals than did a placebo.” However, in an important additional finding they report that “repeated doses of modafinil were unable to prevent deterioration of cognitive performance over a longer period of sleep deprivation though maintaining wakefulness and possibly even inducing overconfidence in a person’s own cognitive performance.” Such conclusions tie in with Schermer et al. who have suggested that “[s]ince this [methylphenidate] is a psychostimulant it does keep you awake and alert. However, it does not appear to have effect on concentration or sustained attention in healthy volunteers. Moreover, while methylphenidate enhances executive function on novel tasks, it impairs previously established performance.” In assessing the potential benefits of modafinil, Schermer et al. are slightly more dismissive of these benefits, stating that “modafinil improves performance in only 6 out of 29 cognitive tests” . Moreover, a further caveat to our understanding of risks and benefits is that that benefits tend to be inversely proportional to IQ; a significant issue if we are to consider that the main users of cognitive enhancers appear to be within the student and academic community .
In summary, these drugs—which are commonly associated with cognitive enhancement—have some side effects but are generally well tolerated when used in typical doses. Indeed, the perceived (by users) safety of using these drugs is both understandable in the light of this evidence, but is also of concern with respect to popular perceptions that these drugs are harmless . Similar to their mild side effects they have only moderate cognitively enhancing properties. On the basis of this evidence, it may be cautiously possible to suggest that the risks, although mild might, not outweigh the benefits. Indeed, given that neurologists and general physicians are currently concerned about how they should deal with requests for cognitive enhancers (see above) they could arguably be reasonably comfortable in dismissing requests from otherwise healthy individuals wanting cognitive enhancers; not because of adverse medical or sociological implications, but largely because they don’t appear to have significant cognitive benefits over and above known risks.
Framework Two: Self-Medication and Under-prescription
It has been suggested that at least some non-medical use of stimulants might be envisaged as self-medication for the self-treatment of undiagnosed learning difficulties of some kind [24, 33, 34]. Although this suggests some questioning of the terms “illicit” or “non-medical use”—commonly associated with cognitive enhancement practices—it remains the case that this population group do not hold a prescription and therefore legally and medically cannot be officially classified as undergoing treatment.
Two inter-related empirical approaches can be taken which appear to support this framework. The first is to re-examine the motivations for non-medical stimulant use. In Rabiner’s study of college students, the three most commonly found motivations of using such drugs were for concentrating better while studying, to be able to study longer, and feeling less restless . The suggestion put forward by Rabiner is that that in part we might be observing a need for self-medication for undiagnosed ADHD symptoms within the student population. Empirical evidence to support this claim is also provided with Teter et al.’s study of student methylphenidate use where concentration and alertness are mentioned as motives by 58% and 43% respectively of the sample population . These motivations are closely aligned to how ADHD in children and adults is diagnosed through observing repeated signs of inattention, hyperactivity, and impulsivity . Furthermore, if such motivations are indicative of self-treatment we could expect the baseline of academic success of students taking cognitive enhancers to be below average due to their undiagnosed cognitive deficits by comparison to the average student body. Indeed, this expectation, although tentative, has been suggested by Rabiner et al. who found that students engaging in cognitive enhancement did indeed have lower than average academic scores and were thus struggling academically in comparison to the main student body (in a similar manner to ADHD-diagnosed children who also often struggle academically) .
The second form of empirical argument is that there is considerable evidence to suggest that many individuals within the population have of ADHD symptoms but are not receiving treatment. Somewhat surprisingly, studies directly recording the rate of symptomology within the adult population (with or without a diagnosis) are somewhat sparse . However, of those large scale studies examining prevalence rates in the population, it is possible to suggest that we may expect some 3–7% of the US adult population to have ADHD [36, 37, 38]. This gives an indication of the scale of the issue. However, more significantly the same studies suggest even in the US where treatment rates are higher than in many other countries only an extremely low percentage of adults with ADHD were receiving treatments; for example Kessler reports that “only 10.9% of the respondents with adult ADHD had received treatment for ADHD in the 12 months before interview”. Similarly, in a study by Poulin conducted in Nova Scotia, Canada the conclusion reached was that just 9.2% of students with a positive ADHD screening test reported being prescribed methylphenidate or dextroamphetamine . Clearly, there is considerable empirical evidence to suggest under-treatment of adult ADHD in the population.
In combination these recorded motivations, statistical evidence of under-treatment of ADHD, and relatively poor educational achievement (by comparison) provide considerable support for this framework of understanding the non-medical use of stimulant. In concluding this framework it may be suggested either that we revise the expectation the such non-medical use of stimulants for academic purposes is necessarily cognitive enhancement on the basis of being undertaken by truly healthy individuals, or we reflect upon the difficulty of separating self-treatment from enhancement. As indicated in the following quote from Rabiner’s study of students self-medicating “[s]tudents without prescriptions use ADHD medication primarily to enhance academic performance and may do so to ameliorate attention problems that they experience as undermining their academic success [italics added]”. As the quote suggests, it may be difficult to separate enhancing academic performance from ameliorating attentional problems and thus when speaking of cognitive enhancement we should be concerned that we may indeed be referring (in part) to self-treatment.
Framework Three: Prescription Drug Abuse and Over-Prescription
A third framework by which to understand the non-medical use of stimulants is as a form of prescription drug abuse. Support from this position appears to be particularly strong among public health professionals . Similarly, the position is closely allied to the findings of Banjo et al., who found one of the main concerns held by physicians regarding requests for cognitive enhancement among young people without a diagnosable health condition was the possibility of drug diversion .
There are several empirical strands to the overarching argument, each one suggestive of an environment whereby we can envisage cognitive enhancement as a form of prescription drug abuse. The first type of empirical argument made is that given the extraordinary rise in the prescription of psychotropic drugs, it is almost inevitable that a certain percentage of these drugs become diverted to illicit use . Indeed, this has been found to be the case. In a study conducted among adolescents in a southeast Michigan school district, Boyd et al. found that around 21% gave away or loaned their stimulant medications. This seems to be in line with other drug prescription abuse—the same study recording that 25% gave away or loaned their pain medications and a further 21% gave away or loaned their stimulant medications (similar figures were estimated for sleeping medications) . Studies of this type are relatively infrequent, although it has been strongly argued that where there are high levels of drug prescription we can expect proportionally high levels of drug diversion . This generalized data adds weight to the argument that what is sometimes seen as cognitive enhancement (by way of non-medical stimulant use) can be understood as another form of prescription drug abuse.
The second argument is that drug such as methylphenidate (drugs used to treat ADHD) are particularly prone to one form of drug diversion tactic; faking of symptoms. The overall argument is that ADHD drugs come to be used for a variety of motives (including cognitive enhancement) due to a combination of opportunity and secondary educational and other benefits. With respect to opportunity, according to Harrison et al. as yet there are no biomarkers for ADHD and no consistent test available for diagnosing ADHD “with adequate diagnostic sensitivity and specificity”. The problem of diagnosing in adults is particularly prone to false positives given that the diagnosis relies heavily on self-reporting of current and childhood behaviors; a form of reporting that lends itself to recall bias . Harrison’s research appears to show that both inadvertent and deliberate faking can occur. In Harrison et al.s blind study involving true positive (those with ADHD symptoms), true negatives (those according to the study team did not have ADHD symptoms), and deliberate fakers (instructed to fake symptoms), existing tests “incorrectly classified a number of Honest Normals as possibly having ADHD” and additionally, and of greater concern, the faking group had an “almost perfect ability” to be diagnosed as having ADHD according to the current Conners’ Adult ADHD Rating Scale. Thus in this study, there is a strong suggestion that there is considerable opportunity to be falsely diagnosed, and, thus obtain such drugs through deception . With respect to motivation, according to Sullivan et al. “data suggest that significant numbers of college students demonstrate poor effort in the context of ADHD and LD [learning difficulty] evaluations” furthermore, the authors suggest that this lack of effort and the magnification of symptoms to obtain a diagnosis is “motivated by secondary gain potentials” . They list these motivations as including “psychostimulant medications that can be misused, abused, and misdirected.” Furthermore, they estimate that the “base rate for symptom exaggeration among college students self-referred for ADHD evaluations might be estimated at approximately 25–48%.”; a somewhat higher estimate of fakery and exaggeration than would be expected for other neurological symptoms (although comparison of figures is extremely difficult) . (Other gains are more directly educational including extra time given for examinations and elimination of penalties for poor spelling) . In line with these findings, it has been strongly suggested that validity tests are included in ADHD testing [43, 44, 45, 47]. Such tests, it is tentatively claimed, may detect faking as ‘fakers’ tend to exaggerate symptoms to such a degree that they regularly get lower score on validity tests than true positives.
In approaching the non-medical use of stimulantd as prescription drug abuse there is much to support the public health framing of cognitive enhancement as prescription drug abuse. We should not be surprised that this form of drug diversion may be on this rise as this appears to be largely a by-product of the rise in legitimate prescription rates. Far more concerning however, is the possibility that the symptoms necessary for a prescription are relatively easily simulated. In summation, we can reasonably assume that inadvertent over-prescriptioning in is occurring (even if this does not negate the possibility that under-prescriptioning is also occurring). Furthermore, if we are concerned in any manner to address the problem of cognitive enhancement as a subset of non-medical stimulant use it is suggested that this frame provides avenues by which to explore the problem of as an issue of prescription practices, especially within the context of an educational setting where motivations and opportunity appear to be significant influences on the access to the drugs required for cognitive enhancement.
Framework Four: Cognitive Enhancement
The final framework by which we can envisage some elements of non-medical stimulant use is as a form of cognitive enhancement. Thus, if we remove the other frames provided (or take these into account as significant caveats to our understanding of cognitive enhancement practices), we can envisage this non-medical use of stimulants as being undertaken for the purpose of augmenting cognitive abilities in some manner. Indeed, this is the framework suggested by Greeley et al. is stating that “on university campuses around the world, students are striking deals to buy and sell prescription drugs such as Adderall and Ritalin—not to get high, but to get higher grades”  or, as argued by Farah et al. that “the enhancement of normal neurocognitive function by pharmacological means is already a fact of life for many people” .
Empirically this argument is supported by several of the sociological studies provided above. As has been argued by Teter et al. the most commonly reported motives for illicit use of prescription stimulants were to help with concentration and alertness . Similarly, White et al. list motivations for use in the following order “(1) to improve attention, (2) for partying, (3) to improve study habits, (4) to improve grades, and (5) to reduce hyperactivity” . It is suggested that if we come to understand such motivations as being held by truly ‘healthy’ individuals we can interpret such survey data as indicative of cognitive enhancement practices. Potentially adding some weight towards the argument (at least that some of this motivation is not driven by the need to self-medicate) it has been demonstrated that students who are members of fraternities and students attending universities with high-entrance levels have above-average rates of non-medical stimulant use . This data does not negate the possibility that a different motivation could be relevant to individuals who are struggling academically, but suggests that some non-medical stimulant use may indeed be for the purposes of cognitive enhancement. Indeed, the low GPA and high-achieving groups both noted for relatively high non-medical stimulant use points to the need to distinguish such motivational categories in relation to baseline academic achievement.
In addition to these sociological studies, there is anecdotal evidence that some individuals believe themselves to be cognitively enhancing. As an example, a student at Queen’s University (Ontario, Canada) is reported as stating “the material becomes so interesting, you don't want to move, go to the bathroom, eat, or do anything. And you remember all of it” . More (in)famously, a student at the University of Harvard is widely reported to have told the Washington Post: “In all honesty, I haven't written a paper without Ritalin since my junior year in high school” . Other sociological evidence backs up this belief in efficacy, despite the lack of support from experimental data. In their study of motivation, Rabiner et al. found that around 70% of users of ADHD medication without a prescription felt their experience was “positive or very positive” with more frequent users rating highest on the scale .
Such findings are important, but do not necessarily answer questions as to whether this can distinguish between enhancement and self-treatment. Such positive perceptions could be because the drugs did effectively enhance, but could also be the result of the person successfully self-treating their ADHD without knowing this. Similarly, there is some evidence to suggest that individuals taking such drugs are prone to exaggerate the benefits cognitively; becoming overconfident in their abilities . As is noted by Advocat, students taking such enhancers are not known to have necessarily higher examination scores . Instead of assuming that cognitive enhancement is necessarily an easily defined motivation, it is perhaps best to note that students are motivated by a variety of factors such as time pressures and the need to be alert while studying. It should be noted that such alertness is not necessarily seen as improving academic achievement. Indeed as Hall et al. notes, students using such drugs to stay alert “did not believe that stimulants helped them on tests, or more generally with academics” . These reports suggest that there is a considerable amount that we do not know concerning both motivation and self-evaluated efficacy in use; although we cannot discount the possibility that efficacious cognitive enhancement is being experienced by some individuals.
Discussion: Framing and Ethical Issues
It has been argued that the discussion of cognitive enhancement as an issue of ethical controversy is predicated upon assuming that such enhancement practices are currently found in the use of drugs such as methylphenidate and modafinal by healthy individuals. This distinction between ‘healthy’ persons choosing to engage in non-medical usage (potentially classed as cognitive enhancement) and ‘unhealthy’ persons requiring treatment (the medical use of stimulants) is questionable [52, 53]. However, it is argued that analytically this distinction remains essential if we are to maintain a measure—quantitative or qualitative—of cognitive enhancement practices (regardless of whether we feel the borderline to be incorrectly placed, blurred, or ever-changing). As such, it has been suggested that if we wish to deduce the scale of such cognitive enhancement practices we should search for such practices within the wider categorisations of non-medical and illicit use of stimulant drugs. However, as this paper has indicated, it should not be assumed that all forms of non-medical stimulant use are necessarily forms of cognitive enhancement. Potentially the most clear-cut distinction is between recreational use (to get high and party) and educational use (as seen above). Less easy to distinguish is the use of such drugs to treat undiagnosed ADHD or other learning difficulties. Moreover, even within that which may be defined as cognitive enhancement we remain extremely unclear as to what might be perceived as the objectives of this enhancement.
Using these frames to develop caveats to our understanding of cognitive enhancement, it is suggested, firstly that we cannot assume—as is sometimes the case in bioethics literature wishing to address the consequences of widespread and efficacious use of cognitive enhancements—that such enhancement objectives are necessarily met by drug efficacy. Similarly, we cannot and should not discount the significance of safety issues. Amphetamine and similar stimulant use among the healthy has a long, well-documented, but frequently under-emphasised history . The history of previous generations of stimulant use suggests that we have a tendency to initially over-emphasise efficacy and under-emphasis side-effects .
Secondly, we cannot assume that it is self-evident that people who may be classified in the broad generalist term of cognitive enhancement are necessarily healthy individuals wanting to use such drugs to go beyond normal cognitive abilities; it is entirely possible that individuals who might be seen as cognitively enhancing may reasonably have ADHD symptoms that have not been diagnosed and treated [24, 33]. It is entirely feasible that we may wish to label this self-treatment as a form of enhancement, but subsequently we would struggle to avoid a suggestion that all forms of neurological treatments are enhancements (and therefore subject to the same ethical debates). (Interestingly, this may not be a particularly novel idea as “cognitive enhancement” is already associated more strongly in the psychiatric literature with treatments for Alzeihemers, Parkinson’s Disease, and Schizophrenia; as opposed to the more recent use of the term in relation to healthy individuals as used in bioethics). A number of diagnostic issues may well be pertinent to this framework of understanding cognitive enhancement as a derived, in part, from self-medication. The medical profession and bioethics may wish need to work together revise the diagnosis to increase the sensitivity of the diagnostic tests in operation. Or, perhaps given evidence that it is the diagnostic criteria used are over-sensitive test (as suggested above) we may need to gather further information as to why people carrying the burdens of ADHD and associated learning difficulties might avoid self-referring for such diagnosis; despite the extraordinary rise in the diagnosis it may still be the case the adult ADHD sufferers are stigmatised in the population) . These discussions are important; but for the purposes of this paper, the key issue is that if we wish to engage in discussions concerning such usage, the cognitive enhancement debate as it stands is at best inappropriate and at worst damaging; do we really want to suggest the individuals hoping to alleviate ADHD symptoms should be denied access to these drugs on the basis of equity of distribution?
Thirdly, it is has been suggested that cognitive enhancement could be seen as a subset of prescription drug diversion. This framework provides us with important questions regarding prescription control and law enforcement. As has been argued above, in terms of distribution the supply of cognitive enhancers is not unusual. However, a number of important questions remain concerning this framework. Considering the relatively high profile of this problem and the considerable controversy—especially with respect to Ritalin—it is interesting to note that as recently as 2007, Inciardi has highlighted how little we know about prescription drug diversion general . Although we know a majority of trade is informal through friends, currently we are not sure what percentage of the approximately 20% of drugs diverted come from this friends who have faked symptoms and others with genuine ADHD [15, 18]. Moreover, with individuals who have a genuine diagnosis of ADHD (true positives) it is not clear if they suffer any negative medical consequences from giving away or trading a certain percentage of their drugs. These will be important data in order to develop strategies to reduce prescription drug diversion. However, while such questions are important in practical terms, the key element for this argument is that there may be little to distinguish the sourcing of cognitive enhancers from other forms of illicit prescription drug use. Furthermore, given the relatively high rate of overlap found between students who felt they were using such drugs recreationally and for study purposes (Rabiner reports this overlap at 40% of students using stimulants for both academic and nonacademic reasons) , we can presume that much illicit stimulant use blurs the boundary between illicit drug use and enhancement (staying up late to party and study is not an inconceivable scenario). Mirroring the discussion of self-treatment and enhancement, we could suggest from this framework that all forms of illicit (and licit) drug use could be seen as enhancements. Indeed, in the eyes of the law there is no distinction between using stimulants without a prescription for enhancement or for recreational use . Again current ethical discussions of cognitive enhancement do not address these questions about drug criminalisation or legalisation and say very little about authenticity in relation to all drug taking experiences.
Fourth, and finally it has been suggested that cognitive enhancement is indeed being practiced is as it seems. Some people do indeed wish to cognitively enhance—and are nominally and actually ‘healthy.’ Clearly, this does not negate the necessity to get hold of the drugs for enhancement, but for the present it is suggested that some individuals do practice cognitive enhancement, and furthermore, as discussed below, it is suggested that they themselves feel enhanced in some manner. Only in this form of practice is it suggested that our current debates are appropriate reflections of current practices. However, in granting this appropriateness we must be extremely cautious that we do not include other forms of practice as forms of cognitive enhancement thereby inflating the numbers of people engaged in this activity and subsequently inflating the relevance of the current bioethical discussion to people engaged in the non-medical use of stimulants. In short, it is argued that 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. In providing these frames, it has not been the intention to simply negate the possibility for cognitive enhancement, but instead to provide alternative avenues by which to explore what may be encompassed within this term, and subsequently the types of practical ethical and medical issues that may emerge. In combination, these frames offer significant challenges to how cognitive enhancement is conceptualised and challenge academics interested in cognitive enhancement to reflect upon how the use of this term impacts upon the popular perception of cognitive enhancement.
Conclusion: Reification, Reflection, and Coercion
It is tempting to suggest that bioethics has been caught up in self-generated argument concerning this use of stimulants, especially within an educational setting. In doing so, the discipline may have reified or exaggerated the importance of cognitive enhancement as an issue of identifiable practice. Indeed, if we are to focus upon the first three frameworks provided in the above discussion, we have no need to discuss enhancement at all. Instead we only need to address risks and benefits of particular drugs (including their use by people without a diagnosis) alongside any remedial action to avoid both the potential for under and over-diagnosis of ADHD especially, or any diagnosis related to access to the drugs currently associated with access to drugs used for cognitive enhancement purposes (stimulants). However, although this reification and hyperbole argument has considerable merit, there does remain (at least in far more limited scope than is often assumed) both a genuine observable practice—reflected in this terminology—and a useful reflexive discussion to be had concerning cognitive enhancement.
With respect of the ability for bioethics to reflect upon cognitive enhancement practices; it will be recalled that a student at the University of Harvard is widely reported to have told the Washington Post: “In all honesty, I haven't written a paper without Ritalin since my junior year in high school” . Whether this self-perceived benefit qualifies as placebo effect, a delusion from over-confidence in the drug, an implicit admission of addiction, or a prime example of cognitive enhancement remains impossible to verify. However, what is not at question is the perception that such drugs have enhancement properties. In addition, it will be recalled that a high-achieving student Queen’s University also perceived strong benefits to taking methylphenidate and furthermore. Furthermore she is reported as claiming that around half the people she knows take such drugs to get them through their examinations . Bioethics, in suggesting that cognitive enhancement is both efficacious and widespread may indeed be reifying and reflecting upon popular perceptions rather than scientific and sociological realities. However, in addition, it is reflecting upon something more; the perception that these drugs are OK or safe to use and that if everyone is using them it is not only acceptable but also beneficial ‘for me’ to use them. Given this gap between expectation and empirical evidence, it can be suggested that term cognitive enhancement as used in the current bioethics discussion does indeed have some saliency reflecting the tension between legitimate and illegitimate (ethically) use of stimulants. Bioethics—in its reflexive mode—is correct to highlight the tension between individual choice and societal coercion to use enhancers in a competitive world . Indeed, if there a particular arena in which bioethics has been successful in reflecting upon cognitive enhancement it is in the potential for the social pressure to use such drugs to grow exponentially when it is perceived that everyone is doing the same thing.
By way of conclusion, given that we may want to both comment on what may be seen as important ethical issue; but at the same time do not want to be caught in the trap of inadvertently reifying or exaggerating the impact of cognitive enhancement—how is that bioethics should rehabilitate the cognitive enhancement debate? For an answer to this question it is suggested that reflect upon the following definition of cognitive enhancement, “the use of drugs and other interventions to modify brain processes with the aim of enhancing memory, mood and attention in people who are not impaired by illness or disorder” . It is suggested that if the bioethics community continues to be concerned about the current and future direction of cognitive enhancement, contributors to the debate should continually stress that cognitive enhancement is the aim of enhancing memory, mood, and attention. Furthermore, contributors to the debate should be extremely cautious about assuming this aim is achievable, that non-medical use such stimulant drugs is for the purposes of enhancement, and that we are not simply witnessing a new and soon to-be-declining fad in drug taking. Finally, if bioethics is sure that enhancement practices are taking place, the discipline needs to pay far greater attention to the types of enhancing effects are being sought and potentially adjust our language to make it more appropriate to the intended effects desired. Without such cautious approaches, the terminology of cognitive enhancement lends itself far too easily towards creating and reinforcing the misperceptions and hyperbole that may inadvertently become part of the coercive process.
The author would like to thank Professor Wayne Hall of the Addiction Neuroethics unit University of Queensland for comments on an earlier draft of this paper.
Research funded by Canadian Institutes of Health Research, NNF 80045, States of Mind: Emerging Issues in Neuroethics
Conflict of Interest
- 4.Chatterjee, A. 2006. The promise and predicament of cosmetic neurology. Journal of Medical Ethics 32: 110e13.Google Scholar
- 5.Farah, Martha J., Judy Illes, Robert Cook-Deegan, Howard Gardner, Eric Kandel, Patricia King, Eric Parens, Barbara Sahakian, and Paul Root Wolpe. 2004. Neurocognitive enhancement: What can we do and what should we do? Nature Reviews: Neuroscience: 421–5.Google Scholar
- 10.Banjo, O.C., R. Nadler, and P.B. Reiner. 2010. Physician attitudes towards pharmacological cognitive enhancement: Safety concerns are paramount. PLoS One 5(12). doi:10.1371/journal.pone.0014322.
- 14.BMA. Boosting your Brainpower: Ethical Aspects of Cognitive Enhancement. 2007. available from http://www.bma.org.uk/images/Boosting_brainpower_tcm41-147266.pdf, [accessed 21 February 2011].
- 16.Barrett, S.P., C. Darredeau, L.E. Bordy, and R.O. Pihl. 2005. Characteristics of methylphenidate misuse in a university student sample. Canadian Journal of Psychiatry 50(8): 457–461.Google Scholar
- 21.Johnston, L. D., O’Malley, P. M., Bachman, J. G., and Schulenberg, J. E. 2010. Monitoring the Future national survey results on drug use, 1975–2009: Volume II, College students and adults ages 19–50 (NIH Publication No. 10–7585). Bethesda, MD:National Institute on Drug Abuse. Table 2–2.Google Scholar
- 23.Johnston, L. D., O’Malley, P. M., Bachman, J. G., and Schulenberg, J. E. 2010. Monitoring the Future national survey results on drug use, 1975–2009: Volume II, College students and adults ages 19–50 (NIH Publication No. 10–7585). Bethesda, MD:National Institute on Drug Abuse. Table 2–2 p.47.Google Scholar
- 28.Kooij, J.J.S., H. Burger, A.M. Boonstra, P.D. Van Der Linden, L.E. Kalma, and J.K. Buitelaar. 2004. Efficacy and Safety Of Methylphenidate in 45 Adults With attention-deficit/hyperactivity disorder. A randomized placebo-controlled double-blind cross-over trial. Psychological Medicine 34(6): 973–982.CrossRefGoogle Scholar
- 30.Schermer, M., I. Bolt, R. de Jong, and B. Olivier. 2009. The future of psychopharmacological enhancements: Expectations and policies. Neuroethics 2 (2): 75–87Google Scholar
- 32.Partnership Attitude Tracking Study (Teens) DEA. 2009. Available from: www.getsmartaboutdrugs.com/identify/partnership_attitudetracking_study_teens.html. [Accessed 8 June, 2011].
- 34.Wilens, T.E., L.A. Adler, J. Adams, S. Sgambati, J. Rotrosen, R. Sawtelle, L. Utzinger, and S. Fusillo. 2008. Misuse and diversion of stimulants prescribed for ADHD: A systematic review of the literature. Journal of the American Academy of Child & Adolescent Psychiatry 47(1): 21–31.CrossRefGoogle Scholar
- 35.DSM-IV-TR® Diagnostic and Statistical Manual of Mental Disorders. Available at: http://www.psychiatryonline.com/content.aspx?aID=7721&searchStr=attention-deficit%2fhyperactivity+disorder [accessed 12 June, 20111]
- 36.Kessler, Ronald C., Lenard Adler, Russell Barkley, Joseph Biederman, C.Keith Conners, Olga Demler, and Stephen V. Faraone. 2006. The prevalence and correlates of adult ADHD in the united states: Results from the national comorbidity survey replication. American Journal of Psychiatry 163: 716–723.CrossRefGoogle Scholar
- 40.INCB. 2009. International Narcotics Control Board Report. Available: http://www.incb.org/pdf/annual-report/2009/en/AR_09_English.pdf (accessed Jan 20, 2011).
- 49.Richmond, Vanessa and Cohen, Lindsay. Up All Night With New Study Aids. Available at http://www.straight.com/article/up-all-night-with-new-study-aids [accessed 13 June 2011].
- 50.Laurance, Jeremy. 2003. Ritalin abuse hits students looking for an exam kick. Available at: http://www.independent.co.uk/news/education/education-news/ritalin-abuse-hits-students-looking-for--an-exam-kick-537088.html [accessed 13 June 2011].
- 52.Chadwick, Ruth Therapy, Enhancement and Improvement. In: Ruth Chadwick B. Gordijn, R. Chadwick (eds.) Medical Enhancement and Posthumanity. Springer Science & Business Media BV.Google Scholar
- 56.Inciardi, James A., Hilary L. Surratt, Steven P. Kurtz, and Theodore J. Cicero. 2007. Mechanisms of prescription drug diversion among drug-involved club and street-based populations. Pain Medicine 8(2): 171–183.Google Scholar
- 57.Downie, J., S. Outram, and F. Campbell. 2010. Caveat Emptor, Venditor, Et Praescribor: Legal Liability Associated With Methyplenidate Hydrochloride (MPH) Use By Postsecondary Students. Health Law Journal 18: 51–71.Google Scholar
- 58.Forlini, Cynthia and E. Racine. 2009. Autonomy and Coercion in Academic “Cognitive Enhancement” Using Methylphenidate: Perspectives of Key Stakeholders Neuroethics 2:163–177.Google Scholar