Neuroethical Issues in Cognitive Enhancement: the Undergraduates’ Point of View
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To date, legitimacy of the application of cognitive enhancement programs to healthy individuals is still fueling neuroethics discussions. The aim of the present investigation is analyzing naïve conceptions of the ethical implications of different practices—namely, non-invasive brain stimulation (NIBS), psychotropic drugs, diet, hydration, and physical activity—which can be followed to enhance cognitive performance. An online survey targeted the opinions of the general public about the efficacy of the neuroenhancement techniques and ethical concerns in different contexts. Measures of general self-efficacy and beliefs about intelligence have been collected as well. Responses of 89 Italian undergraduate students of medicine or psychology were analyzed statistically and thematically. Findings supported the notion that passive ways of enhancing human performance, which fail to imply any personal effort and individual responsibility, are conceived as infringing moral rules, regardless of the context where they are implemented.
KeywordsCognitive enhancement Neuroethics Neuromodulation tDCS Psychotropic drugs General self-efficacy Implicit theories of intelligence
Attempts to enhance human intellectual skills have a long history, being motivated by the need to cope with the environment efficiently, the desire to excel in the social context, and the aspiration to reach a sense of personal fulfillment. In recent years, the goal to improve one’s own cognitive abilities, usually achieved by training mental processes through repeated exercises and/or by learning effective strategies and self-regulatory approaches, can be reached also thanks to external aids (Colzato and Hommel 2016). This raises a series of concerns (Farah 2015) and questions these new ways to empower cognitive functions (Bostrom and Sandberg 2009).
Two tools have been mainly taken into account because of their ethical implications: the use of pharmacological cognitive enhancers (Greely et al. 2008; Castaldi et al. 2012) and non-invasive brain stimulation (NIBS) (Cohen Kadosh et al. 2012). Both manipulate brain processes and have therefore drawn attention to a set of problems since the notion that neural activity can be altered by outside by artificial agents such as synthetic molecules (Ragan et al. 2013) and low-intensity electric currents (Lapenta et al. 2014) puts in question the true nature of human beings (Buchanan 2009). It was also claimed that trying to improve cognitive capabilities through such external aids undermines the authenticity of the person (Sandel 2007). More circumstantial arguments concern the fact that drugs and NIBS prevent the enhancement of mental skills by means of personal effort and engagement, which are the usual ways in which people achieve personal goals and produce a sense of self-achievement. Instead, they lead to overestimating the value of the performance against that of the learning process (Schermer 2008). Furthermore, social issues have been underlined: because of a lack of financial or logistic resources, not everybody has access to cognitive enhancers. Hence, inequality is increased (Parens 1998). Finally, whereas the use of drugs and NIBS is not questioned when they are applied for therapeutic or rehabilitative purposes, their employment with healthy individuals becomes problematic since it is not easy to demarcate the boundaries between pathology and normality (Daniels 2000).
These topics have been discussed mainly among the experts in the field. Opinions of people who are in charge of applying enhancing drugs (Schelle et al. 2014) and NIBS (Riggall et al. 2015) have been investigated a few times. Little attention, however, has been paid to attitudes, beliefs, and naïve conceptions of individuals who are the target of interventions based on such enhancement tools. The aim of the present paper was indeed to shed light on what a specific category of potential beneficiaries of those tools—namely, university students, who are a population targeted by them (Singh et al. 2014; Looi and Cohen Kadosh 2015)—think about a series of ethical issues which are associated with cognitive enhancers. Some individual characteristics have been taken into account, as well the personal conception of the changeability of intelligence and self-efficacy, which have been assumed to modulate the view one has about the efficacy and legitimacy of the cognitive enhancers in question.
An anonymous online survey, administered in Italian, was hosted through Qualtrics (www.qualtrics.com). The survey was developed, based on co-authors consensus, to address the ethical issues shortly discussed in “Introduction.” After providing consent to participate in the investigation, demographics (age, gender), and university studies information (field of study, year of study), respondents completed a survey with 17 close-ended questions addressing behaviors, attitudes, and opinions towards the use of new neuroenhancement methods (i.e., psychotropic drugs and NIBS), covering six domains: (a) knowledge and familiarity (four questions); (b) opinions about the efficacy (five questions); (c) ethical concerns (four questions); (d) openness to use for self-enhancement (one question); (e) social judgement perception (two questions); and (f) likelihood estimation of the consequences on society, on the basis of scientific data about efficacy (one question). Before presenting questions addressing them, both psychotropic drugs and NIBS were briefly described: “The use of psychotropic drugs consists in the oral intake of a synthetic substance which affects brain functioning” and “Neuromodulation consists of the application of a weak electrical current through a region of the scalp to increase cortical plasticity of the corresponding brain area.”
Familiarity with neuroenhancement was explored by asking participants whether they had ever heard of the methods previously described and, if so, to indicate how many people they knew who used one of them.
To better address the specific familiarity and opinions about efficacy of the investigated neuroenhancement methods, participants were also asked to compare psychotropic drugs and NIBS to more general personal care practices, such as healthy diet, hydration, and physical activity, which are sometimes associated with cognitive enhancement.
Opinions on the effectiveness were collected by asking participants if they believed it was possible to enhance cognitive performance by psychotropic drugs and NIBS (answer options: yes, no) and, if so, to give their enhancement estimation as percentage.
As for the ethical concerns, participants were asked to rate the fairness of neuroenhancement use on a 5-point scale (1 = absolutely unfair; 2 = quite unfair; 3 = I cannot tell if it is fair or not; 4 = quite fair; 5 = absolutely fair) for each of the two methods considered and in three different hypothetical situations (i.e., academic achievement, strategy game competition, and employment proficiency). Furthermore, participants were asked to express their level of agreement (1 = strongly disagree; 2 = slightly disagree; 3 = slightly agree; 4 = strongly agree, 5 = completely agree) with different arguments supporting the unfairness of neuroenhancement, for each of the two target methods (11 items): (1) “Only those who can afford it can benefit from it”; (2) “Only those who live in a place where neuroenhancement is offered can benefit from it”; (3) “It distorts the assessment of merit”; (4) “It can induce an addiction”; (5) “It leads people to not commit”; (6) “It makes people passive”; (7) “It denaturalizes individuals”; (8) “It leads people to not consider themselves capable of self-improvement”; (9) “It induces a sense of omnipotence”; (10) “It makes people fake”; and (11) “It causes people to overly focus on success.”
To investigate social judgement perception, participants were presented the following questions: “What would the people closest to you think if you told them you took cognitive enhancing drugs regularly?” and “What would the people closest to you think if they found out you were receiving neurostimulation to enhance your cognitive performance?”, to which they had to answer using a 5-point level of approval scale (1 = would surely disapprove; 2 = would probably disapprove; 3 = would be unsure; 4 = would probably approve; 5 = would surely approve).
A 5-point level of consideration scale (1 = would definitely not consider; 2 = might not consider; 3 = hard to tell; 4 = would likely consider; 5 = would definitely consider) was used to rate the openness to use neuroenhancement for self-improvement in different hypothetical study-related situations (nine items): (1) “University exam at the end of a semester in which you could not really study because you had a demanding job”; (2) “To improve graduation results, since undertaking your dream career requires much better grades than you had so far”; (3) “To reach up to your partner who usually has much better grades than you”; (4) “To impress your parents”; (5) “To shorten the long hours you would have to study otherwise”; (6) “To compensate for the study time you lost due to an illness”; (7) “To not be disadvantaged compared to your classmates who use cognitive enhancement”; (8) “To reduce the gap in the basic preparation necessary for your course, which your classmates have from attending a different high school”; and (9) “To make up for your study difficulties, which are caused by a learning disability.”
Opinions about consequences on society were investigated by asking participants to judge the likelihood (1 = it would definitely not happen; 2 = it would likely not happen; 3 = it could or could not happen; 4 = it would likely happen; 5 = it would definitely happen) of potential consequences of the use of neuroenhancement, on the basis of reported scientific data about efficacy. More precisely, a between-subject question addressing the consequences on society was included, manipulating the results of the cited scientific study: “Suppose a research study came out which showed that a particular psychotropic drug would increase cognitive performance up to n%. How likely are the following reactions to this study?”, with n being 3% for half of respondents (N = 45) and 30% for the other half (N = 44).
Finally, in order to control for individual underlying factors related to the representation of cognitive performance, the General Self Efficacy Scale (Sibilia et al. 1995), measuring respondents’ beliefs in their ability to succeed in specific situations, and the Implicit Theories of Intelligence Scale (Dweck and Leggett 1988), a measure of whether respondents believed intelligence was a fixed quantity or something that could be increased with effort, were administered as well.
An invitation e-mail was sent to a sample of undergraduate students from two universities in Lombardy, Northern Italy, who were attending courses in the field of psychology or medicine. Such a target population could be expected to have a basic knowledge of cognitive abilities and neuroenhancement, which was required to comprehend the issues addressed by the survey.
Demographic and university studies information of survey respondents
Mean (SD) age (years)
Fields of study:
Year of study:
Responses were analyzed quantitatively. Statistical analyses included descriptive statistics (means/percentages), related sample comparisons (Wilcoxon signed-rank test), and independent sample comparisons (Mann–Whitney U test), as appropriate to the research question. An alpha level of 0.05 was used, which was adjusted using the Bonferroni correction in post-hoc procedures and multiple comparisons (α/number of comparisons).
Knowledge and Familiarity
The majority of respondents answered that they “had heard about the use of psychotropic drugs for improving cognitive performance” before (N = 71, 79.8%), whereas only approximately half of respondents (N = 41, 46.1%) had already heard about NIBS.
Furthermore, when they were asked if they knew someone who had taken psychotropic drugs with the sole purpose of enhancing their cognitive abilities, 16.9% of respondents (N = 16) answered “yes” and indicated on average a number of 2.31 people (SD = 1.59). Similar ratings were reported about the use of personal care practices, specifically diet and physical activity: 14.6% of respondents (N = 13) reported to know an average of 3.77 people (SD = 5.0) who adjusted their eating habits and physical activities with the sole purpose of improving their cognitive performance (n of people comparison: Z = − 1.41; ns).
Opinions on the Efficacy
Most of respondents reported to believe in the effectiveness of neuroenhancement techniques. More precisely, they agreed that it was possible to use psychotropic drugs (N = 71, 79.8%) and NIBS (N = 65, 73.0%) to enhance cognitive performance.
Whereas previous knowledge about psychotropic drugs did not have a role in orienting the believes about its efficacy (χ2 = 0.55; ns), the great majority of respondents who were already familiar with NIBS (N = 37/41, 90.0%) were also convinced of its efficacy for cognitive enhancement (χ2 = 11.43; p < .005).
Regarding the extent of the enhancement, participants estimated that it was possible to increase one’s cognitive performance by approximately 30% using either psychotropic drugs (M = 28.52; SD = 15.52) or NIBS (M = 27.57; SD = 17.95) (comparison: Z = − 0.24; ns). Previous knowledge about the techniques was not associated with enhancement estimation ratings for either drug (U = 305.0; ns) or NIBS (U = 371.5; ns).
Estimated improvement was similar, however with greater variability, for diet (M = 27.25; SD = 27.50) and physical exercise (M = 26.74; SD = 24,09), but lower for hydration (M = 23.43; SD = 23.12). Non-parametric comparisons between enhancement estimation of drugs, NIBS, diet, hydration, and physical exercise were non-significant, except for drugs vs diet (Z = − 3.17, p < .01).
Neither the level of self-efficacy nor an incremental theory of intelligence—assessed by following the norms of the two instruments we applied—were found to be associated with the belief in neuroenhancement efficacy (general self-efficacy 1.23 < χ2 < 1.87; ns; incremental theory of intelligence 0.68 < χ2 < 1.64; ns) or the estimation of its effect on cognitive performance (general self-efficacy 446.5 < U < 878.0; ns; incremental theory of intelligence 476.5 < U < 928.0; ns).
Fairness ratings were higher for the use of NIBS for academic (M = 2.62; SD = 1.19) and employment achievement (M = 2.55; SD = 1.24), followed by the use of drugs for academic achievement (M = 2.27; SD = 1.20), employment achievement (M = 2.12; 1.28), and the use of NIBS (M = 1.89; SD = 1.03) and drugs (M = 1.63; SD = 0.99) for a strategy game competition.
In all proposed hypothetical situations, NIBS was rated significantly fairer as compared to psychotropic drugs (academic achievement: Z = − 3.26; p < .005; strategy game competition: Z = − 3.12; p < .005; employment achievement: Z = − 362; p < .0001).
For both psychotropic drugs and NIBS, scholastic and employment achievement received similar fairness ratings (drugs: Z = − 1.30; ns; NIBS: Z = − 0.40; ns), whereas neuroenhancement was rated significantly less fair in strategy gaming, relative to academic achievement (drugs: Z = − 5.20; p < .0001; NIBS: Z = − 5.45; p < .0001) and employment achievement (drugs: Z = − 4.55; p < .0001; NIBS: Z = − 5.04; p < .0001).
Neither self-efficacy nor an incremental theory of intelligence appeared to have a role in orienting ethical believes (general self-efficacy 711.0 < U < 987.5; ns; incremental theory of intelligence 644.5 < U < 981.0; ns).
Openness to Self-Use
Openness to self-use of neuroenhancement was associated neither with self-efficacy level (695.0 < U < 936.0; ns) nor an incremental conception of intelligence (806.0 < U < 978; ns).
Social Judgement Perception
Respondents reported very low ratings of social approval perception of neuroenhancement. Disapproval perception was significantly higher for psychotropic drugs rather than NIBS (Z = − 4.5; p < .0001). Only one participant (1.1%) thought the people closest to him would “probably approve his regular use of cognitive enhancement drugs,” whereas according to five participants (5.6%), their close ones would probably approve their use of NIBS. Uncertainty ratings were more frequent for NIBS (44.9%, N = 40), compared to drugs (14.6%, N = 13). Overall, no participant selected the option “they would surely approve.”
Social judgement perception was found to be associated neither with self-efficacy (784.5 < U < 907.5; ns) nor an incremental theory of intelligence (873.5 < U < 927; ns).
Likelihood Estimation of the Consequences on Society
As for the consequences on society of the use of psychotropic drugs for neuroenhancement, on the basis of different alleged research data about its efficacy, similar likelihood ratings were reported for the great majority of options, regardless of the extent of enhancement efficacy (i.e., 3% vs 30% improvement). Greater enhancement effects on cognition were associated with a significantly higher likelihood estimation only for the increase in prescription demand (3% improvement: M = 3.48; SD = 0.94; 30% improvement: M = 4.00; SD = 0.72; comparison: U = 672.5; p < .005).
Both participants who were presented findings about a smaller (+ 3%) and a greater (+ 30%) effect of the drug considered more likely to happen the following consequences: “A greater number of people will try to get a prescription of the drug” (3% improvement 56.5%; 30% improvement 83.7%); “The use of the drug will increase considerably” (3% improvement 56.5%; 30% improvement 79.1%); “Stronger control measures for the drug will be requested” (3% improvement 60.9%; 30% improvement 79.1%); and “The users of the drug will more easily admit to take it” (3% improvement 58.7%; 30% improvement 44.2%).
Although our sample of respondents consisted of university students who were being trained in psychology or medicine, only half of the sample reported to have heard about NIBS before completing the survey. Knowledge about the possibility to use psychotropic drugs to enhance cognitive performance was more widespread (approximately 80% of participants had previously heard about it).
Most respondents showed to be confident about the effectiveness of both neuroenhancement techniques. Familiarity was found to be relevant in orienting the assessment of neuroenhancement efficacy only for NIBS, whereas having a previous knowledge of the use of psychotropic drugs was not necessary for believing in their effectiveness. However, the estimation of the extent of cognitive improvement which could be induced by neuroenhancement was similar for both methods, regardless of familiarity (approximately 30%). More general personal care practices, such as a healthy diet and physical activity, were considered almost as effective as drugs and NIBS in inducing neuroenhancement (approximately 27%), whereas a proper hydration was reported to be slightly less reliable, however receiving an average estimation of 23%. Such results do not support the perception of specificity and relevance of the investigated methods for improving cognitive abilities, as compared to unspecific healthy behaviors.
Overall, the largest portion of participants considered both neuroenhancement methods unfair, regardless of the context where they are implemented and the goal which is meant to be achieved. Nevertheless, some differences emerged between NIBS and drugs, the former being considered less unfair in all contexts of potential application. Furthermore, neuroenhancement was judged less unfair when performed for academic and employment achievement, as compared to a strategy game competition.
The arguments supporting the unfairness of neuroenhancement which received the highest agreement ratings concerned addiction risk, merit distortion, and perception of self-improvement incapability. As for the last argument, it would be plausible to assume that such importance attributed to the perception of self-improvement would be associated with high levels of self-efficacy and with the implicit tendency to have an incremental theory of intelligence. However, such underlying factors were not related to any of the attitudes and opinions explored by the survey.
Consistently with the unfairness judgement, respondents would not consider using neuroenhancement methods for self-improvement in most situations, except for overcoming study difficulties caused by a learning disability, or for compensating lost study time due to an illness. The notion of disability or impairment seems to be crucial in determining one’s acceptance to receive neuroenhancement for self-improvement.
As for the perception of social judgement, according to the largest portion of the sample, the people closest to them would not approve their use of neuroenhancement techniques. Such disapproval was considered even stronger for psychotropic drugs, relative to NIBS.
Finally, scientific data about the efficacy of the use of a psychotropic drug for cognitive enhancement did not appear to be relevant when respondents were asked to rate the likelihood of potential consequences of its distribution, except for an increase of prescription demand.
The decision to recruit respondents only among psychology and medicine courses was driven by the need for participants to have a basic knowledge on the concept of neuroenhancement and on the investigated techniques. However, such selection is a limitation to the generalization of the results. It is worth, in the near future, to investigate the answers of students from other courses to measure the potential variability in the results.
The present investigation aimed at exploring the behaviors, attitudes, and opinions about ethical concerns of university students, who were being trained in the fields of psychology or medicine, towards two neuroenhancement methods, namely psychotropic drugs and NIBS.
Since undergraduates are one of the main categories of alleged beneficiaries of pharmacological enhancers and NIBS, investigating their conceptions about such tools is worthy in order to understand to what extent they are aware of the underlying ethical questions. This should help in devising the appropriate way to present neuroenhancement techniques to students, foresee their perplexities, and to find relevant arguments to explain the aims of pharmacological and NIBS devices, as well as their limits. Obviously, the attempt is neither to induce students to necessarily share the reasons supporting the application of neuroenhancement by removing possible prejudices and suspects nor, in contrast, to elicit negative attitudes to discourage their use. Rather, the aim should be to foster a critical approach so that everyone can develop a personal view on the basis of a deep consideration of all the facets of the question. If we know in advance what the undergraduates’ “naïve” theories about neuroenhancement are, we can identify which points merit attention when we are presenting them to the students.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that there is no conflict of interest.
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