, Volume 8, Issue 3, pp 243–256 | Cite as

Empirical Support for the Moral Salience of the Therapy-Enhancement Distinction in the Debate Over Cognitive, Affective and Social Enhancement

  • Laura Y. CabreraEmail author
  • Nicholas S. Fitz
  • Peter B. Reiner
Original Paper


The ambiguity regarding whether a given intervention is perceived as enhancement or as therapy might contribute to the angst that the public expresses with respect to endorsement of enhancement. We set out to develop empirical data that explored this. We used Amazon Mechanical Turk to recruit participants (N = 2776) from Canada and the United States. Each individual was randomly assigned to read one (and only one) vignette describing the use of a pill to enhance one of 12 cognitive, affective or social (CAS) domains. The vignettes described a situation in which an individual was using a pill to enhance the relevant domain under one of two possible enhancement conditions, one perceived as enhancing above the norm (EAN), what most people recognize as a clear case of enhancement, whereas the other perceived as enhancing towards the norm (ETN), with the individual using the enhancement having a modest, but subclinical deficit. Participants were asked how comfortable they were with the individual using the enhancement and about the impact the enhancement might have had in the individuals’ success in life. We found that irrespective of the domain to be enhanced, participants felt significantly more comfortable with ETN than with EAN, and they regarded the enhancement intervention as contributing to greater success in life with ETN rather than EAN. These data demonstrate that the therapy enhancement distinction is morally salient to the public, and that this distinction contributes to the angst that people feel when considering the propriety of CAS enhancement.


Enhancement to the norm Enhancement above the norm Experimental neuroethics Public attitudes Cognitive Social Affective 



Supported by a grant from the Canadian Institutes of Health Research. We thank Jordan Mowat for his work as a second coder.

Supplementary material

12152_2014_9223_MOESM1_ESM.pdf (112 kb)
ESM 1 (PDF 112 kb)


  1. 1.
    Daniels, Norman. 1985. Just Health Care- Studies in philosophy and health policy. New York: Cambridge University Press.Google Scholar
  2. 2.
    Daniels, Norman. 2008. Just health. New York: Cambridge University Press.Google Scholar
  3. 3.
    Daniels, N. 1992. Growth Hormone Therapy for short stature: Can we support the treatment/enhancement distinction. Growth: Genetics & Hormones 8: 46–48.Google Scholar
  4. 4.
    President’s Council on Bioethics. 2003. Beyond therapy. Washington: President’s Council on Bioethics.Google Scholar
  5. 5.
    Presidential Commission for the Study of Bioethical Issues. 2014. Gray matters: Integrative approaches for neuroscience, ethics, and society. Vol. 1. Presidential Commision for the Study of Bioethical Issues. Accessed 06 June 2014.
  6. 6.
    Bostrom, Nick, and Julian Savulescu. 2009. Human enhancement ethics: The state of the debate. In Human enhancement, ed. Julian Savulescu and Nick Bostrom, 1–22. Oxford: Oxford University Press.Google Scholar
  7. 7.
    Harris, John. 2007. Enhancing evolution. New Jersey: Princeton University Press.Google Scholar
  8. 8.
    Cabrera, Laura Y. 2011. Between different Human enhancement paradigms: the role of Nano and Neurotechnology. CSU Research Output. Accessed 17 February 2014. 
  9. 9.
    Coenen, Christopher, Mirjam Schuijff, Martijntje Smits, Pim Klaassen, Leonhard Hennen, Michael Rader, and Gregor Wolbring. 2009. Human enhancement. European Technology Assessment Group. Accessed 17 February 2014. 
  10. 10.
    Lin, Patrick, and Fritz Allhoff. 2008. Untangling the debate: The ethics of human enhancement. NanoEthics 2: 251–264. doi: 10.1007/s11569-008-0046-7.CrossRefGoogle Scholar
  11. 11.
    Buchanan, Allen, Dan W Brock, Norman Daniels, and Daniel Wikler. 2001. From chance to choice. Cambridge University Press.Google Scholar
  12. 12.
    Bostrom, Nick. 2008. Drugs can be used to treat more than disease. Nature 451: 520. doi: 10.1038/451520b.CrossRefGoogle Scholar
  13. 13.
    Reiner, P B. 2013. The Biopolitics of Cognitive Enhancement. In Cognitive enhancement: An interdisciplinary perspective, eds. E. Hildt and A. G. Franke, 189–200. Trends in Augmentation of Human Performance 1. Springer.Google Scholar
  14. 14.
    Butcher, James. 2003. Cognitive enhancement raises ethical concerns. The Lancet 362: 132–133. doi: 10.1016/S0140-6736(03)13897-4.CrossRefGoogle Scholar
  15. 15.
    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 5: 421–425.CrossRefGoogle Scholar
  16. 16.
    Turner, Danielle C., and Barbara J. Sahakian. 2006. Neuroethics of cognitive enhancement. BioSocieties 1: 113–123. doi: 10.1017/S1745855205040044.CrossRefGoogle Scholar
  17. 17.
    Sahakian, Barbara J., and Sharon Morein-Zamir. 2011. Neuroethical issues in cognitive enhancement. Journal of psychopharmacology (Oxford, England) 25: 197–204. doi: 10.1177/0269881109106926.CrossRefGoogle Scholar
  18. 18.
    Racine, Eric, and Cynthia Forlini. 2008. Cognitive enhancement, lifestyle choice or misuse of prescription drugs? Neuroethics 3: 1–4. doi: 10.1007/s12152-008-9023-7.CrossRefGoogle Scholar
  19. 19.
    Heinz, Andreas, Roland Kipke, Hannah Heimann, and Urban Wiesing. 2012. Cognitive neuroenhancement: False assumptions in the ethical debate. Journal of Medical Ethics 38: 372–375. doi: 10.1136/medethics-2011-100041.CrossRefGoogle Scholar
  20. 20.
    Ravelingien, A., J. Braeckman, L. Crevits, D. De Ridder, and E. Mortier. 2009. “Cosmetic neurology” and the moral complicity argument. Neuroethics 2: 151–162. doi: 10.1007/s12152-009-9042-z. Springer Netherlands.CrossRefGoogle Scholar
  21. 21.
    Nadler, Roland C, and Peter B Reiner. 2010. A call for data to inform discussion on cognitive enhancement 5. Nature Publishing Group: 481–482. doi: 10.1057/biosoc.2010.30.
  22. 22.
    Fitz, Nicholas S., Roland Nadler, Praveena Manogaran, Eugene W.J. Chong, and Peter B. Reiner. 2014. Public attitudes toward cognitive enhancement. Neuroethics 7: 173–188. doi: 10.1007/s12152-013-9190-z.CrossRefGoogle Scholar
  23. 23.
    Schelle, Kimberly J., Nadira Faulmüller, Lucius Caviola, and Miles Hewstone. 2014. Attitudes toward pharmacological cognitive enhancement—a review. Frontiers in Systems Neuroscience 8: 1–14.CrossRefGoogle Scholar
  24. 24.
    Schicktanz, Silke, Mark Schweda, and Brian Wynne. 2012. The ethics of ‘public understanding of ethics’—why and how bioethics expertise should include public and patients’ voices. Medicine, Health Care and Philosophy 15: 129–139.CrossRefGoogle Scholar
  25. 25.
    Burstein, Paul. 2003. The impact of public opinion on public policy: A review and an agenda. Political Research Quarterly 56: 29–40. doi: 10.1177/106591290305600103.CrossRefGoogle Scholar
  26. 26.
    Kaye, Sharlene, and Shane Darke. 2012. The diversion and misuse of pharmaceutical stimulants: What do we know and why should we care? Addiction 107: 467–477. doi: 10.1111/j.1360-0443.2011.03720.x.CrossRefGoogle Scholar
  27. 27.
    Burstin, Kenneth, Eugene B. Doughtie, and Avi Raphaeli. 1980. Contrastive vignette technique: An indirect methodology designed to address reactive social attitude measurement. Journal of Applied Social Psychology 10: 147–165. doi: 10.1111/j.1559-1816.1980.tb00699.x.CrossRefGoogle Scholar
  28. 28.
    Cabrera, Laura Y, and Peter B. Reiner. (submitted). A novel sequential mixed-method technique for quantification of unscripted narratives: Contrastive quantitized content analysis: 1–18.Google Scholar
  29. 29.
    Cabrera, Laura Y, Nick S. Fitz, and Peter B. Reiner. (2014). Reasons for comfort and discomfort with pharmacological enhancement of cognitive, affective, and social domains. Neuroethics. doi: 10.1007/s12152-014-9222-3.
  30. 30.
    Knobe, Joshua, and Bertram F. Malle. 2002. Self and other in the explanation of behavior: 30 years later. Psychologica Belgica 42: 113–130.Google Scholar
  31. 31.
    Willis, Gordon. 2004. Cognitive interviewing. Research Triangle Institute. Accessed 20 May 2014.
  32. 32.
    Berinsky, Adam J., Gregory A. Huber, and Gabriel S. Lenz. 2012. Evaluating online labor markets for experimental research:’s mechanical Turk. Political Analysis 20: 351–368. doi: 10.1093/pan/mpr057.CrossRefGoogle Scholar
  33. 33.
    Buhrmester, Michael, Tracy Kwang, and Samuel D. Gosling. 2011. Amazon’s mechanical Turk: A new source of inexpensive, yet high-quality, data? Perspectives on Psychological Science 6: 3–5.CrossRefGoogle Scholar
  34. 34.
    Paolacci, Gabriele, Jesse Chandler, and Panagiotis G. Ipeirotis. 2009. Running experiments on Amazon Mechanical Turk. Judgment and Decision Making 5: 411–419.Google Scholar
  35. 35.
    Mason, Winter, and Siddharth Suri. 2012. Conducting behavioral research on Amazon’s Mechanical Turk. Behavior Research Methods 44: 1–23.CrossRefGoogle Scholar
  36. 36.
    Ipeirotis, Panagiotis G. 2010. Demographics of Mechanical Turk. Research Gate. Accessed 18 February 2014.
  37. 37.
    Paolacci, Gabriele, and Jesse Chandler. 2014. Inside the Turk: Understanding mechanical turk as a participant pool. Current Directions in Psychological Science 23: 184–188. doi: 10.1177/0963721414531598.CrossRefGoogle Scholar
  38. 38.
    Curran-Everett, Douglas, and Dale Benos. 2004. Guidelines for reporting statistics in journals published by the American Physiological Society. American Journal of Physiology-Endocrinology and Metabolism 287: E189–E191. doi: 10.1152/ajpendo.00213.2004.CrossRefGoogle Scholar
  39. 39.
    Cumming, Geoff. 2014. The new statistics: Why and how. Psychological Science 25: 7–29. doi: 10.1177/0956797613504966.CrossRefGoogle Scholar
  40. 40.
    Chi, Michelene TH. 1997. Quantifying qualitative analyses of verbal data: A practical guide. The Journal of the Learning Sciences 6:271–315. doi: 10.1207/s15327809jls0603_1.
  41. 41.
    Braun, Virginia, and Victoria Clarke. 2006. Using thematic analysis in psychology. Qualitative Research in Psychology 3: 77–101. doi: 10.1191/1478088706qp063oa.CrossRefGoogle Scholar
  42. 42.
    Onwuegbuzie, Anthony J. 2003. Effect sizes in qualitative research: A prolegomenon. Quality and Quantity 37:393–409. doi: 10.1023/A:1027379223537.
  43. 43.
    Östlund, Ulrika, Lisa Kidd, Yvonne Wengström, and Neneh Rowa-Dewar. 2011. Combining qualitative and quantitative research within mixed method research designs: A methodological review. International Journal of Nursing Studies 48: 369–383. doi: 10.1016/j.ijnurstu.2010.10.005.CrossRefGoogle Scholar
  44. 44.
    Sandelowski, Margarete, Corrine I. Voils, and George Knafl. 2009. On quantitizing. Journal of Mixed Methods Research 3: 208–222. doi: 10.1177/1558689809334210.CrossRefGoogle Scholar
  45. 45.
    Daniels, Norman. 2000. Normal functioning and the treatment-enhancement distinction. Cambridge Quarterly of Healthcare Ethics : CQ: The International Journal of Healthcare Ethics Committees 9: 309–322.CrossRefGoogle Scholar
  46. 46.
    Sabini, John, and John Monterosso. 2005. Judgments of the fairness of using performance enhancing drugs. Ethics & Behavior 15: 81–94. doi: 10.1207/s15327019eb1501_6. Lawrence Erlbaum Associates, Inc.CrossRefGoogle Scholar
  47. 47.
    Bostrom, Nick, and Anders Sandberg. 2009. Cognitive enhancement: Methods, ethics, regulatory challenges. Science and Engineering Ethics 15: 311–341. doi: 10.1007/s11948-009-9142-5.CrossRefGoogle Scholar
  48. 48.
    Chan, Sarah, and John Harris. 2008. In support of human enhancement. Studies in Ethics, Law, and Technology 1: 1–3.CrossRefGoogle Scholar
  49. 49.
    Horvath, J., and T. Grundmann. 2013. Experimental philosophy and its critics. London: Routledge.Google Scholar
  50. 50.
    Williamson, T. 2011. Philosophical expertise and the burden of proof. Metaphilosophy 42: 215–229.CrossRefGoogle Scholar
  51. 51.
    Savulescu, Julian. 2006. Justice, fairness, and enhancement. Annals of the New York Academy of Sciences 1093: 321–338. doi: 10.1196/annals.1382.021.CrossRefGoogle Scholar
  52. 52.
    Bostrom, Nick. 2011. Smart policy: Cognitive enhancement and the public interest. In Enhancing human capacities, ed. J. Savulescu, Ruud, and G. Kahane, 138–152. Oxford: Wiley-Blackwell.Google Scholar
  53. 53.
    Sandberg, Anders, and Julian Savulescu. 2011. The social and economic impacts of cognitive enhancement. In Enhancing human capacities, ed. J. Savulescu, R. ter Meulen, and G. Kahane, 92–112. Oxford: Wiley.Google Scholar
  54. 54.
    Harris, J. 2009. Enhancements are a moral obligation. WellcomeScience: 16–17.Google Scholar
  55. 55.
    Persson, Ingmar, and Julian Savulescu. 2008. The perils of cognitive enhancement and the urgent imperative to enhance the moral character of humanity. Journal of Applied Philosophy 25: 162–177. doi: 10.1111/j.1468-5930.2008.00410.x.CrossRefGoogle Scholar
  56. 56.
    Quigley, Muireann. 2009. Enhancing Me, Enhancing You: Academic Enhancement as a Moral Duty. Expo 2. doi:10.1558/expo.v2i2.157.Google Scholar
  57. 57.
    Farah, M.J., and P. Root Wolpe. 2004. Monitoring and manipulating brain function: New neuroscience technologies and their ethical implications. Hastings Center Report 34: 35–45.CrossRefGoogle Scholar
  58. 58.
    Forlini, Cynthia, and Eric Racine. 2012. Added stakeholders, added value(s) to the cognitive enhancement debate: Are academic discourse and professional policies sidestepping values of stakeholders? AJOB Primary Research 3: 33–47. doi: 10.1080/21507716.2011.645116. Taylor & Francis Group.CrossRefGoogle Scholar
  59. 59.
    Forlini, C., and E. Racine. 2012. Stakeholder perspectives and reactions to “academic” cognitive enhancement: Unsuspected meaning of ambivalence and analogies. Public Understanding of Science 21: 606–625. doi: 10.1177/0963662510385062.CrossRefGoogle Scholar
  60. 60.
    Franke, Andreas G., Klaus Lieb, and Elisabeth Hildt. 2012. What users think about the differences between caffeine and illicit/prescription stimulants for cognitive enhancement. PLoS ONE 7: e40047. Public Library of Science.CrossRefGoogle Scholar
  61. 61.
    Hotze, Timothy D., Kavita Shah, Emily E. Anderson, and Matthew K. Wynia. 2011. “Doctor, would you prescribe a pill to help me … ?” A national survey of physicians on using medicine for human enhancement. The American Journal of Bioethics 11: 3–13. doi: 10.1080/15265161.2011.534957.CrossRefGoogle Scholar
  62. 62.
    Ott, R., and N. Biller-Andorno. 2014. Neuroenhancement among Swiss students–a comparison of users and non-users. Pharmacopsychiatry 47: 22–28. doi: 10.1055/s-0033-1358682.Google Scholar
  63. 63.
    Dodge, Tonya, J. Kevin, Miesha Marzell Williams, and Rob Turrisi. 2012. Judging cheaters: Is substance misuse viewed similarly in the athletic and academic domains? Psychology of Addictive Behaviors 26: 678–682. doi: 10.1037/a0027872.CrossRefGoogle Scholar
  64. 64.
    Dubljevic, Veljko, Sebastian Sattler, and Eric Racine. 2014. Cognitive enhancement and academic misconduct: A study exploring their frequency and relationship. Ethics & Behavior 24: 408–420. doi: 10.1080/10508422.2013.869747.CrossRefGoogle Scholar
  65. 65.
    Beddington, John, Cary L. Cooper, John Field, Usha Goswami, Felicia A. Huppert, Rachel Jenkins, Hannah S. Jones, Tom B.L. Kirkwood, Barbara J. Sahakian, and Sandy M. Thomas. 2008. The mental wealth of nations. Nature 455: 1057–1060. doi: 10.1038/4551057a.CrossRefGoogle Scholar
  66. 66.
    Nussbaum, Martha, and Amartya Sen. 1993. The Quality of Life. Oxford: Clarendon Press.Google Scholar
  67. 67.
    Sen, Amartya. 1979. Equality of What? the Tanner Lecture on Human Values. Standford University.Google Scholar
  68. 68.
    Nussbaum, M.C. 1992. Human functioning and social justice in defense of Aristotelian essentialism. Political Theory 20: 202–246. Sage Publications.CrossRefGoogle Scholar
  69. 69.
    Little, M.O. 2000. Cosmetic surgery, suspect norms, and the ethics of complicity. In Enhancing human traits: Ethical and social implications, ed. E. Parens, 162–176. Washington, DC: Georgetown University Press.Google Scholar
  70. 70.
    Conrad, Peter, and Valerie Leiter. 2004. Medicalization, markets and consumers. Journal of Health and Social Behavior 45: 158–176.Google Scholar
  71. 71.
    Watts, Geoff. 2012. Critics attack DSM-5 for overmedicalising normal human behaviour. BMJ 344: e1020. doi: 10.1136/bmj.e1020.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  • Laura Y. Cabrera
    • 1
    Email author
  • Nicholas S. Fitz
    • 1
  • Peter B. Reiner
    • 1
  1. 1.National Core for NeuroethicsThe University of British ColumbiaVancouverCanada

Personalised recommendations