Substance Use

Abstract

This chapter starts out with a theoretical discussion of the meaning of “drug”. As it turns out, three different kinds of psychoactive drugs can be distinguished. Central to this distinction is the understanding of appropriate medical use, which is subject to change. Historical examples illustrate how our personal and also governments’ ways to think about drugs changed since the nineteenth century. In the past, colonial authorities were the biggest drug traders and countries even waged war to enforce open markets. Cocaine, opium, and nitrous oxide (laughing gas) are addressed in detail. The legal regulation of that last substance even changed as the book was being written. The framework for people’s instrumental substance use is then introduced. It distinguishes different reasons for which drugs can be instrumentalized. Several common substances are described subsequently, addressing their respective risks and benefits. The final section presents important values that can guide moral decisions about drug use.

The fundamental urge to alter our consciousness in significant but controllable ways is, it seems, part of our hard-wiring. Very few people live their lives without using some kind of mind-altering substance, be it a cup of coffee, a glass of wine, sleeping pills, cigarettes or betel.

—Ken Arnold, Head of Public Programmes, Wellcome Collection, London (in: Jay, 2010, p. 6)

We have just concluded that there are no clear boundaries between disorder/disease, health/normality, and enhancement. This does not deny that there are many individual cases which we can meaningfully identify as either disease (e.g., a malignant tumor) or enhancement (e.g., implants to equip people with infrared vision). However, the inability to find clear definitions of these concepts becomes highly relevant in this chapter on substance use. After all, the legal distinction between licit and illicit drugs, between freely available substances and regulated drugs, depends very much on whether medical and administrative authorities consider them as a valid treatment for a medical disease or mental disorder. With what we have learned in Chap. 2, we can say that these decisions are examples of pragmatism and social constructionism, but that they are also guided by the drugs’ intrinsic properties, which reflects essentialism (see also Schleim, 2018).

The classifications eventually made and maintained by the authorities responsible for drug policy can and do have serious consequences for many people: Will they have access to a substance legally, or do they risk being sentenced, in severe cases to years in prison, merely for its possession? By avoiding the reification of present distinctions between licit and illicit drugs, we can better understand how this system evolved in the twentieth century. The first section of this chapter will thus discuss the theoretical difference between nutritional supplements, natural stimulants (such as alcohol, coffee, and tobacco), licit, and illicit drugs. This is then exemplified with a couple of illustrative historical cases in the second section. The subsequent section on instrumental use will systematize the topic of this chapter, and to a certain extent the whole book, from the present perspective. The final section discusses different values that may underlie and guide decisions on substance use.

4.1 Kinds of Substances

Substances—think of the sugar extracted from sugarcane or beet, the caffeine in coffee beans, the cocaine extracted from coca leaves, or the methylphenidate synthesized from other chemical compounds—do not come with a label telling us what they are good (or bad) for. Their effects and side effects are something we humans have to find out for ourselves. The distinction between natural and unnatural means, which often plays a role in ethical debates, does not help us much. Just as natural substances can have therapeutic effects when used properly—such as St. John’s wort (Hypericum perforatum), which has been found to be similarly effective in treating mild-to-moderate depression as some of the frequently prescribed pharmaceutical drugs used today (Ng et al., 2017)—there are also many poisons in nature. Furthermore, the wisdom of Paracelsus (c. 1493–1541), who said that “the dose makes the poison”, is still valid and illustrates once more that a spectrum of distinctions is much more appropriate than concepts that suggest clear borders.

Similar to the analysis of the history and meaning of “addiction” in Chap. 2, we should spend some time in this chapter looking at where the present classification system of substances comes from and what this “present system” is after all. When preparing this section, I had the problem, for example, that there is no direct corresponding term in many languages for the German term Genussmittel or the Dutch genotmiddel, literally meaning something that is consumed for enjoyment or as a mild stimulant (see Hengartner & Merki, 1999; Schivelbusch, 2010). In debates on drug policy, this term often functions to positively frame substances not primarily consumed for their nutritional value, while distinguishing them from the “bad drugs” (Droge or drug in the two languages).

Some English dictionaries translate Genussmittel as “(natural) stimulant” (similar to the Spanish el estimulante, for example), while others just list a number of substances: “alcoholic drinks, coffee, tea, tobacco, etc.” We call the latter an “enumerative definition” in philosophy, which is commonly used when we have no better idea about what to call something. People and cultures in different times would probably disagree on what to add to the list (see Goodman et al., 2007). Speaking of “stimulants”, by contrast, has the downside of blurring the line with the strictly regulated stimulant drugs we discussed in detail in the previous chapter. Furthermore, this would not do justice to the fact that the consumption of alcohol beyond a certain threshold quickly leads to severe impairment of cognitive functioning.

4.1.1 Three Kinds of Drugs

That the English language knows no equivalent for Genussmittel may explain the ambiguity of its term “drug”. Some link its etymology to Old French drogue (Tupper, 2012), meaning “any substance, of animal, vegetable, or mineral origin, used as an ingredient in pharmacy, chemistry, dyeing, or various manufacturing processes” (ibid., p. 465). As an extension of this, the Oxford Dictionary of English (online edition) relates it to Dutch droog, literally meaning “dry”, referring to dried, often colonial goods, sold in the “drug store” even today (Dutch drogisterij, German Drogerie). Kenneth W. Tupper, a researcher on psychedelic substances and adjunct professor of population and public health at the University of British Columbia in Canada, distinguishes three meanings of “drug” in contemporary English, referred to as drug₁, drug₂, and drug₃.

The first is synonymous with “medicine” and contains substances which are psychoactive or not. Tupper explains that when coca products and opium were increasingly marketed as “drugs” in the early twentieth century, pharmacists in the US launched a concerted campaign to preserve this term for medicine in the more narrow sense (Tupper, 2012; see also Parascandola, 1995). Roughly 100 years later, we now know that this failed. The meaning of drug₂ is “a chemical substance other than a food that alters consciousness when absorbed into the body” (Tupper, 2012, p. 466). The focus here thus lies on the psychoactive effects, also reflected in the phrase “to drug someone”. Some of these substances can be medicines in the sense of drug₁, others can be legal but regulated, such as alcohol, and yet others can be prohibited, such as cocaine and heroin. The meaning of drug₂ is thus independent of the legal status of the substance.

This is different for drug₃, which refers to “a plant or chemical substance that alters human consciousness and has been subjected to the most rigorous forms of control––typically criminalization––under the international drug control regime” (ibid., p. 467). Drugs₃ are thus the prohibited subset of drugs_2, and this idea reflects how Droge or drug are commonly, perhaps even exclusively, used in German or Dutch, respectively. Almost all substances discussed in this book are drugs in the sense of drug₂, because of the way they interact with the human nervous system. An exception are those substances primarily used to shape the body, which we will briefly address below, and which might require yet another concept, drug₄. As we will see in the next sections, it is common for substances to shift between drug₁ and drug₃ status, depending on how influential groups in society think of them, particularly lawmakers and those in the medical world.

4.1.2 Classification Systems

We can now compare this theoretical summary with the way the authorities deal with drugs practically: In the US, for example, the Controlled Substances Act of 1971 distinguishes five categories in Schedule I to V. Those substances included in the first are considered to have a high potential for “abuse”, but without being of medical use, at least not according to the general opinion in medicine. Schedule II substances are perceived as similarly dangerous, because of their potential to lead to severe psychological and physical dependence, but are also accepted for their therapeutic applications. The prescription stimulants we addressed in so much detail previously fall into this category. Schedules III to V are then increasingly viewed as less harmful.

Many other countries have enacted a similar system, reflecting the same rationale, such as the one established by the Misuse of Drugs Act of 1971 in the United Kingdom, which calls the levels “Schedules 1 to 5” and distinguishes substances into Classes A, B, and C. The similarities between these two and many more countries around the world are no coincidence. International treaties, especially the Single Convention on Narcotic Drugs of 1961, the Convention on Psychotropic Substances of 1971, and the Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988, were proliferated through the United Nations, particularly on the initiative of the US. As of 2021, roughly 190 countries have ratified these treaties (International Narcotics Control Board, 2022).

The importance of these treaties should not be underestimated: For example, while this book was being written, the Scientific Service of the German Federal Parliament published a report about the obstacles associated with legalizing cannabis, one of the major projects of the present governing coalition of Social Democrats, Greens, and Liberals. That the European Union independently ratified these treaties poses, according to the report, a serious problem to the planned legalization.¹ Meanwhile, researchers keep criticizing—some of them harshly—the status quo as arbitrary and unscientific. One of them is the neuropsychopharmacologist David Nutt, with whom we are already familiar as one of the participants in the debate on neuroenhancement in the previous chapter. He and the London-based Independent Scientific Committee on Drugs, now simply called “Drug Science”, proposed an alternative account, which is summarized in Box 4.1 (Kupferschmidt, 2014; see also Nutt et al., 2010; van Amsterdam et al., 2015).

Box 4.1 An Alternative View on Drug Harms to the Users

Professor David Nutt and the Independent Scientific Committee on Drugs rated drug harms. Their list of 20 selected substances, from the most to the least dangerous, is as follows:

• 1. Crack cocaine

• 2. Heroin

• 3. Crystal meth

• 4. Alcohol

• 5. Cocaine

• 6. Amphetamine (Speed)

• 7. Gamma-hydroxybutyric acid (GHB)

• 8. Tobacco

• 9. Ketamine

• 10. Benzodiazepine

• 11. Mephedrone

• 12. Cannabis

• 13. Methadone

• 14. butane

• 15. MDMA (Ecstasy)

• 16. Anabolic steroids

• 17. Khat

• 18. LSD (Acid)

• 19. Buprenorphine

• 20. Magic mushrooms

This ranking is based on experts’ estimations. For the harm to users, shown in Box 4.1, physical (e.g., damage to the body, increased mortality), psychological (e.g., dependence), and social factors (e.g., loss of relationships) were quantified (see Nutt et al., 2010). Notice the stark contrast to the legal classification in the UK (Table 4.1). A similar ranking of the harm to others rated aspects such as injury, crime, or family adversities.

Table 4.1 Drug Harms and Prison Sentences, UK

This way of looking at drugs is not without critique, from both within science and by nonscientists. For example, it has been argued, in my view with at least some justification, that alcohol or tobacco look so extremely negative on this assessment due to the high prevalence of their use and that it also makes no sense to compare freely available and strictly prohibited substances in this way (see Caulkins et al., 2011). Caulkins and colleagues also suggested that these experts’ estimations might be biased by the fact that they see disproportionally many severe cases of substance use because of their clinical work as medical doctors. We have also discussed in Chap. 2 that the risk of addiction is a characteristic not only of the consumers and the substance but also of the environment they live in. For this reason, I have refrained from showing the results of the—in my view, somewhat arbitrary—ratings of social harm.

Nevertheless, Nutt and colleagues developed and keep developing a science-based alternative view on drugs. Even if their model is pragmatic and does not represent “the whole truth”, it emphasizes that the official stance of the drug authorities is at least somewhat arbitrary and inconsistent. That alcohol and tobacco appear to be so dangerous to the users is in stark contrast to the legally enforced classification of drug harms. Alcohol, fourth on the scientists’ list (Box 4.1), is regulated such that it may not be made available to minors, but can be bought by adults more or less freely in most countries; by contrast, amphetamine (Speed) and similar stimulants, strictly regulated as Schedule II substances in many countries and even absolutely prohibited in some, are regularly prescribed to children with an ADHD diagnosis in the US, and actually even more commonly to very young children aged 5–12 than those aged 13–17 (Anderson, 2018). Yet, if they later obtain the same substances as adults without a doctor’s prescription, it may be called a felony and lead to a severe prison sentence.

Some might be shocked to read that in Germany, where I grew up, adolescents aged 14 or 15 may still drink beer and wine in public under supervision of their parents (§9 Jugendschutzgesetz, Protection of Young Persons Act). This is described by some as establishing a predisposition for dependence later in life (Schaller et al., 2017), by others as a way to learn responsible use. Probably both sides have a point. However, a comparison with the prevalence of alcohol use and even binge drinking among 8th and 12th graders in the US (Fig. 4.1), where this is illegal in virtually all jurisdictions, questions the meaningfulness of prohibitive arguments. This is even more so, as alcohol consumption has been decreasing for decades in most countries, including the very permissive Germany (Schaller et al., 2017).

Fig. 4.1

Alcohol Use Among 8th and 12th Graders in the US. Prevalence (in percent) of alcohol use among 8th (green) and 12th graders (red) in the US. The prevalence rates for past year (continuous lines), past month (dashed lines), and binge drinking (dashed with dots) are shown. Binge drinking was defined as five or more drinks in a row during the last two weeks. Source: Monitoring the Future (Miech et al., 2022)

We will return to a discussion of possible implications for drug policy in the book’s general conclusion in Chap. 5. For the purpose of the present section, we may conclude that the classification systems authorities use in most countries to regulate substance use neither reflect scientific models nor their citizens’ behavior. A more specific example of the scientists’ critique is provided by David Nutt, who was dismissed from his function as chair of the British Advisory Council on the Misuse of Drugs after comparing the risk of MDMA (Ecstasy) use with that of horse riding—concluding that the latter led to more adverse events (Nutt, 2009). In a later comparison of cocaine and tobacco use in the UK, he concluded that tobacco was much more physically harmful and addictive (Nutt, 2012). For example, while there were 10 times more tobacco than cocaine users in the UK, 400 times (!) as many deaths per year were related to the former. Nevertheless, he also noted that the possible social harms of cocaine—such as poverty, risk-taking, and antisocial behavior—were higher than for tobacco.

The coronavirus pandemic provided unprecedented insights into how social disruption—unlike war zones such as the Vietnam War discussed before—affects people’s substance use in their domestic countries. In Fig. 4.1, we already saw a dip in alcohol use in 2021, most plausibly explained by the fact that this substance is commonly consumed at social events, of which fewer were possible due to measures to reduce the spread of the virus. The same can be seen for other “party drugs” such as MDMA (Ecstasy) or, as we saw in the previous chapter, amphetamine (Speed). However, while alcohol was consumed less on average, the prevalence of high-intensity use (having more than ten drinks in a row in the past weeks) among young adults was the highest measured since 2005 (Patrick et al., 2022). In this age group, cannabis and hallucinogen use reached the highest level recorded since 1988, and cigarette smoking and opioid use reached historical lows (ibid.). While the average use thus dropped in nationwide representative surveys, there might thus have been more individuals with problematic consumption patterns. This could be an indication that some people use drugs—in the sense of drug₂—to cope with their psychological problems. More on this below.

We started this section with a reflection on the meaning of the term “drug” and distinguished in particular two uses, drug₁ (approved medical drugs) and drug₃ (illicit drugs), which are related to the regulation of substances by the authorities. However, we then also saw how the common classification system is criticized by scientists and that there is a considerable number of minors and adults making their own decisions. These are not necessarily those intended by the official rules. We have thus far already addressed some cultural and historical variability in drug policy. Discussing a few telling historical cases in more detail in the next section will help us to better understand the origins of the way we think about substance use today.

4.2 Historical Examples

We addressed alcohol above to illustrate cultural differences in how substances are perceived. This psychoactive organic chemical compound is naturally produced through the fermentation—one might say “digestion”—of sugars by yeasts. It thus occurs in the wild, even without humans producing it, and many animals have been observed consuming it. For example, the pen-tailed treeshrew (Ptilocercus lowii) from Malaysia has been found to drink the fermented nectar of palm trees on a daily basis, which can contain up to 3.8% alcohol, comparable to light beer (Wiens et al., 2008). In human history, alcohol production may have already existed more than 13,000 years ago (Wadley & Hayden, 2015).

As the temperance movement against alcohol and other substances gained momentum around 1900, there were actually debates about whether alcohol was a food or not (see Blair, 1888; Levine, 2006; Tupper, 2012). This may not be so surprising when one considers two historical cultural facts: Firstly, without access to clean drinking water, it was sometimes safer to drink (often diluted) beer or wine, even for children, as the alcohol in them killed germs. Secondly, during Christian fasting periods, it was still allowed to consume beverages, as they were fluid, and they were useful because they nourished the body (Levine, 2006; Schivelbusch, 2010; Spode, 1993). In particular, monks often had to do hard work that required some exertion of energy. This could be provided by beer, which is, after all, produced from grains and high in calories. Many monasteries are still famous today for their breweries.

Being able to afford alcoholic beverages was also a status symbol for citizens, while the poor or ascetics drank potentially polluted water from the wells. Even today, in some Mediterranean countries red wine is perceived as part of a meal rather than considered a psychoactive drug (Spode, 2010). In states with a majority of Muslims, by contrast, alcohol is generally forbidden and its consumption is low to virtually nonexistent. But the historical background is complex: Some schools interpret their religious scriptures as only disallowing prayer or attending service when intoxicated, while others ban it (and gambling) altogether as sinful, while yet other schools think that the prohibition only refers to alcohol made from grapes or dates (Michalak & Trocki, 2006; Ruthven, 2012).

While temperance movements existed in many Western countries around 1900, nowhere else did they become as powerful as in the US, finally leading to a constitutional amendment establishing Prohibition in 1920. Scholars have argued that alcohol was a catalyst for an ongoing culture clash when “native born, middle-class non-urban Protestants […] felt threatened by the working-class, Catholic immigrants who were filling up America’s cities during industrialization” (Reinarman, 1994, p. 93; see also Levine, 1984). In this view, society was split “between an ‘uptown’ that reflected the established Anglo-Saxon culture, typically centred on Sunday attendance at the church, and a ‘downtown’ community of more recent immigrant groups—Italian, Irish, German—whose most visible expression was the crowded tavern on Saturday night” (Jay, 2010, p. 160). Debates about the substance were highly moralized and particularly focused on the values of self-control and productivity. Medicalizing alcohol use by calling it an “addiction”, and thus perceiving it as a major threat to self-control, also occurred in this period and was used as an argument to prohibit the substance (Levine, 1978).

Efforts to move it from drug₂ to drug₃ status were not entirely successful, though, as there were exemptions for religious use—alcohol has a ritual meaning in Christianity and Judaism—and doctors could prescribe “medical liquor” as well (Gitlin, 2010; Okrent, 2010). This not only provided doctors and pharmacists with extra income but also attracted thieves and forgers who would steal or fake the special prescription forms. In general, alcohol production and distribution was taken over by criminals (see Jay, 2010; Okrent, 2010). Instead of paying taxes, they used the money to bribe police officers. Ultimately, the prices on the black market increased considerably, while the quality and safety of the alcoholic beverages decreased, as they sometimes contained the harmful methanol. In addition to administrative, health- and crime-related problems, as well as the fact that the law became increasingly unpopular, the Great Depression contributed to the failure of Prohibition and its repeal in 1933. As other revenues plunged, the government needed income from tax on alcohol. Reminiscent of this financial rationale and while this book was being written, the Japanese National Tax Agency launched the campaign “Sake Viva!” for people aged between 20 and 39 to develop business ideas to make their peers drink more—and thus increase the government’s tax income.²

The example of alcohol illustrates several important points: The way people think about substances and their use can be morally loaded. Some researchers have even characterized this period in the US as “temperance and prohibition crusades” (Levine, 1984, 2006; Reinarman, 1994). In Chap. 2, we discussed the example of tranquilizers, used to deal with initiatives against racial discrimination on the assumption that protesters were suffering from schizophrenia. According to the explanations discussed in this section, here we see an inverted case, where substance use is regulated (i.e., criminalized) to deal with social differences, on the assumption that a particular group was prone to addiction and morally inferior. We also saw how complex it was to prohibit an already common psychoactive substance. The next examples, in contrast to domestic alcohol, concern drugs that were imported from abroad.

4.2.1 Cocaine and Opium

When cocaine—a stimulant drug extracted from coca leaf and domestic to South America—was introduced to Europe in the late nineteenth century, it sparked immediate interest among physicians and researchers. For example, a certain Theodor Aschenbrandt, assistant at the department of pharmacology in Würzburg, Germany, and a military surgeon, is reported to have given the substance to Bavarian soldiers during a maneuver in 1883 (Holmstedt & Fredga, 1981). According to him, the soldiers, who had not been informed about their participation in the “experiment”, better endured hunger, strain, fatigue, and heavy burdens under the influence of the drug.

An enthusiastic report, probably written by Aschenbrandt himself, is believed to have inspired the young Sigmund Freud (1856–1939), then working as a physician in Vienna, also to experiment with cocaine (ibid.). Freud hypothesized that he could treat opium dependence with the stimulant, but these attempts failed and seriously damaged his reputation because he neglected cocaine’s own addictive potential (Bernfeld, 1953; Freud, 1884). However, he and some of his medical colleagues had noticed that the drug numbed their tongues when they consumed it orally, diluted in water. This in turn enabled one of Freud’s colleagues, the ophthalmologist Carl Koller (1857–1944), to make medical history: He applied the substance as the world’s first local anesthetic to make once-dreaded eye surgery much more comfortable for the patients (Grinspoon & Bakalar, 1981).

But times change. While the substance was once considered a medical breakthrough and easily available as tincture in pharmacies, as “cocaine wine”, or even as Coca Cola to treat a variety of common ailments or simply for enjoyment, it is presently considered a Class A substance under the UK Misuse of Drugs Act, thus one of the drugs deemed most dangerous. However, this does not prevent many European citizens (just as people elsewhere) from consuming it. Quite the opposite, as tons of cocaine are smuggled through the harbors of Antwerp or Rotterdam in huge containers every year, to name just one familiar route the drug takes to its many users around the world.

A culturally even more interesting case is opium, made from the seed capsules of the opium poppy (Papaver somniferum). We briefly addressed Opium, the Demon Flower in Chap. 2, a book popular in the 1920s and beyond, which disseminated demonstrably wrong information about drug users and addiction (Graham-Mulhall, 1926). But let us go back to the nineteenth century first, to the colonial past. The British Empire imported a lot of tea from China, but could not offer similarly interesting goods to the Chinese in return. Paying for the tea—also a stimulant, a drug₂—with silver meant a huge trade deficit for Britain (see Jay, 2010).

The colonialists’ convenient “solution” consisted in delivering opium, mostly from India, with the aid of Dutch merchants, another important colonial power at the time. This psychoactive substance was popular in China, and not just among the rich. Many poor people used it to make their lives more bearable and, sometimes, when they became too desperate, also to bring it to an end. The Chinese authorities, however, were against the drug. As a result, the British had to trade with smugglers and thereby risked political tensions. At a time when China was increasingly struggling with floods, famines, and economic problems, British traders (or “drug dealers”?) became keener and approached high officials behind the Emperor’s back. This, in turn, provoked a response from Chinese authorities, who eventually ordered the destruction of almost a year’s supply of opium on June 17, 1839. The British Empire responded by waging the first Opium War (1839–1842), which was followed by another some years later (1856–1860), this time also supported by France. China lost both times and was forced to open its market to the foreign traders. It also had to cede Hong Kong to the British, which still has ramifications today.

While China was flooded with British/Indian opium, the substance was also used in hundreds of freely available medicines in Western countries (Reinarman, 1994). Reportedly, addiction had not been an issue until campaigns in the US were launched against smoking the drug, which was then framed as the “Mongolian vice” (ibid., p. 93). Toward the end of the nineteenth century, opium dens were also called a “Yellow Peril” (Jay, 2010, p. 153) and racist rumors described Chinese men as making white women dependent on the drug to exploit them sexually. This happened after the railroads and gold mines had been built by Chinese immigrants, and they increasingly competed with domestic workers in a period of economic depression (Reinarman, 1994). What an irony of history that some of them who were not only using opium tinctures as a medicine but “dared” to smoke the drug for pleasure—which was perceived as “novel and shocking” (Jay, 2010, p. 153)—were stigmatized and criminalized for using a substance forcefully introduced into their culture decades earlier by British traders.

We could discuss other illustrative cases here, such as demonizing “hemp” as “marijuana”, a “weed with roots in hell” (Jay, 2010, p. 165), stigmatized in a similar way to the “demon flower” of opium in the early twentieth century (Graham-Mulhall, 1926); how Native Americans’ drinking has been framed as a problem by the white majority after teaching them alcohol use in the first place (Holmes & Antell, 2001); how “freebase” became “crack cocaine” and LSD a “threat” to society (Reinarman, 1994). Even coffee and tea have repeatedly featured in “drug scares” in our cultural history (Schivelbusch, 2010; Troyer & Markle, 1994). At present, alcohol is once more becoming a target for researchers who emphasize health risks (Burton & Sheron, 2018), although its consumption has been continuously decreasing in many countries since the 1970s (see, for example, Schaller et al., 2017).

Some scholars have described more generally how class, gender, and race played, and still play, a role in drug policy (see, for example, Denham et al., 2021; Dollar, 2019; Laguna, 2018; Netherland & Hansen, 2016; Tiger, 2017). However, our focus here is on substance use, not policy, although we will briefly return to this in the final conclusion. We will complete this section with an example from very recent history and then systematize what we have learned so far, more or less from the book as a whole, in the subsequent section on instrumental use.

4.2.2 A Current Example

While this book was being written, the Dutch government wanted to prohibit another substance nationwide: laughing gas (nitrous oxide; see also Box 4.2). It is inhaled by some people, who experience a few moments of euphoria and a change in perception. However, some have complained about the dangers and the nuisance associated with its use. Halfway through 2020, about 90 Dutch municipalities had already taken measures to forbid its recreational use.³ Sometimes these initiatives covered only parts of their territory, sometimes a whole city or town, and sometimes specifically bars and clubs. In May 2022, the Dutch Ministry of Health, thus the same institution launching the initiative to fight nonmedical stimulant use among students, as we saw in Chap. 3, submitted a request for advice to the State Council (Raad van State) in The Hague. This institution serves not only as the highest administrative court of the country but also as an adviser to the government. While its reports are not strictly binding, they are an indication of how judges will most likely rule on certain issues.

Box 4.2 A Historical Note on Nitrous Oxide

When inhaled, nitrous oxide can lead to an experience of relaxation, euphoria, or audiovisual changes. It was actually well known among intellectuals in the late 19^th and early twentieth century. The American philosopher and poet Benjamin P. Blood (1832–1919) became acquainted with it as an anesthetic during a dental operation. In his pamphlet The Anaesthetic Revelation and the Gist of Philosophy, he summarized in 34 pages how the gas and other psychoactive substances had opened his mind and enabled him to appreciate the essence of philosophy, “the genius of being” (Blood, 1874, p. 33). This pamphlet was reviewed by none other than the founding father of academic psychology in the US, William James (1842–1910). James, then at the age of 32, “sincerely advise[d] real students of philosophy to write for the pamphlet to its author” and concluded that “[i]t is by no means as important as [Blood] probably believes it, but still thoroughly original and very suggestive.”⁴

Several years later, he wrote about the philosophy of Georg W. F. Hegel (1770–1831) in the renowned journal Mind, which still exists today and is published by Oxford University Press. In a note to that article, James describes how he “made some observations on the effects of nitrous- oxide-gas-intoxication which have made me understand better than ever before both the strength and the weakness of Hegel’s philosophy.” The psychologist writes about a “tremendously exciting sense of an intense metaphysical illumination” in which “[t]ruth lies open to the view in depth beneath depth of almost blinding evidence.” The gas-induced experience gave him “with unutterable power the conviction that Hegelism was true after all, and that the deepest convictions of my intellect hitherto were wrong” (James, 1882, p. 206).

Another couple of years later, meanwhile at the age of 47, he compared alcohol and nitrous oxide in the article “The Psychology of Belief”, again published in Mind. James wrote about the former that “[o]ne of the charms of drunkenness unquestionably lies in the deepening of the sense of reality and truth which is gained therein.” Things would then “seem more utterly what they are, more ‘utterly utter’ than when we are sober.” Referring to Blood’s pamphlet, he adds: “This goes to a fully unutterable extreme in the nitrous oxide intoxication, in which a man’s very soul will sweat with conviction, and he be all the while unable to tell what he is convinced of at all” (James, 1889, p. 322). Mind lists a total of 16 articles containing “nitrous oxide” between 1882 and 1954. A discussion of the veracity of such experiences goes beyond the scope of this book.

The legal initiative would change the Dutch Opium Law (historically dating back to 1919) such that laughing gas would be added to its List II for “soft drugs”. This would strictly regulate trade in the substance and require further safety and control measures. However, on July 13, 2022, the State Council concluded that the government had insufficiently justified the prohibition.⁵ The Council pointed out that the prohibition would be complex because the substance is commonly used in medicine (e.g., as a painkiller or narcotic) and in preparing foods (especially whipped cream). Such applications—remaining legal under the proposed law—would make the establishment of a prohibition on recreational use alone difficult, and it was questionable whether the additional human resources required to enforce the law would be available. The Council also found that the prohibition in the proposed form might be unconstitutional because it did not sufficiently justify a restriction of free trade in the substance, which is a liberal value in itself.

Although that made the prohibition of nitrous oxide in the Netherlands seem unlikely, the Dutch government announced its ban, effective from January 1, 2023, on November 14, 2022.⁶ In the public announcement, the state secretary of the Ministry for Health referred to the “enormous health risk” of the substance and “terrible accidents” related to its use on the road. In reaction to that decision, representatives of the Dutch nitrous oxide merchants immediately declared to step to the courts to have the prohibition overturned. It is now up to the judges to rule on its legitimacy.

For our purpose, it is interesting to see how the dangers were assessed. A report⁷ on behalf of the Ministry of Health stated that the risk for the individual consumer was low to medium, as the substance caused rather mild side effects, such as headache, dizziness, or tingling sensations. These would commonly occur after using 5 to 10 balloons filled with the gas. Poisoning required more than 50 balloons. Damage to public health could be medium to high, insofar as some people experienced paralysis after use, sometimes even serious paraplegia. The mechanism behind this is a reduction in vitamin B₁₂, which can lead to serious damage in the spinal bone marrow; however, this is reported to occur only rarely, after heavy long-term use (Thompson et al., 2015).

The risk of disturbing public order was considered low to medium. On the one hand, nitrous oxide was not associated with an increase in aggression. However, on the other hand, there had been an increase in traffic accidents related to the substance, for example, when drivers filled balloons while driving. Finally, dangers related to organized crime were reported as low, as the substance was readily available through legal means. There were some indications that criminals traded in it, though, as it was financially lucrative.

For the report, 14 experts were asked to quantify these four categories of risk on scales from 0 to 4. Overall, nitrous oxide received an average final score of 6.7 (where 16 would have been the maximum), thus slightly higher than cannabis and somewhat higher than “magic mushrooms” and ketamine (both between 4 and 5 points). In November 2019, the report concluded that, in comparison to an earlier assessment in 2016, the availability of the substance would be high and associated with a lot of nuisance related to trash (i.e., empty containers) and noise in cities, as well as an increase in serious adverse health effects. Therefore, it recommended that measures should be taken to counter its use.

In agreement with what we learned in the previous chapters about classification in general, but also about schemes to distinguish different kinds of substances in this chapter in particular, we can see that the way a drug is perceived differs and changes: Assessments depend not only on a specific time and location but also on who the users are, how many there are, and the way a substance is used. “Drug scares” have been documented for centuries, and substances that were once perceived as medically useful, perhaps even as a breakthrough in patient welfare, such as cocaine and opium, may later be perceived as extremely dangerous.

These decisions are often pragmatic and reflect social constructs, not only the intrinsic properties of a substance. An important reference point for such decisions is the availability of alternatives serving similar medical needs but at lower cost or with a better profile of side effects. Thus, opium was replaced by synthetic painkillers such as Aspirin (acetylsalicylic acid) or stronger synthetic opioids. These opioids, however, are currently being used in pandemic proportions in the US, leading to tens of thousands of premature deaths annually, to which we will return in Chap. 5. For our present purpose, we can conclude that the substances people consume and what powerful groups in society think about this continuously changes. In the process, it is not uncommon for a drug₂ (psychoactive substance) to shift between drug₁ (medicine) and drug₃ (illicit drug), subject to the various factors we identified above. The common ground to all of this is that people use substances for particular reasons, that is, they use them instrumentally.

4.3 Instrumental Use

One of the most important findings of Chap. 3 was that while leading scholars framed the neuroenhancement debate as about improving cognition or becoming smarter, data from actual users suggested quite a different understanding. Consumers, especially students, took the substances to feel better and be more motivated to do the academic work they were supposed to do—or to cope with stress. This kind of “mood modification” was already discussed and investigated by academics in the 1960s and 1970s, when tranquilizers became popular (see Smart & Fejer, 1972). From this perspective, taking drugs appears to be an adaptation to the demands of a certain environment. This has been similarly described for nonmedical prescription stimulant use in the workplace (Sales et al., 2019).

We also addressed examples of what is commonly considered “recreational use”, such as that aimed at experiencing euphoria, intensifying feelings, becoming “high”, relaxing, or losing weight. Weight loss, related to the effect of some stimulants to reduce hunger, does not sound very “recreational”, however, and could better be understood as changing one’s body. This usage, in turn, has been discussed by some scholars more broadly as bodily image and performance enhancement and also includes the use of anabolic steroids and human growth hormones (Askew & Williams, 2021; Hope et al., 2021).

The common denominator for all of these variants of human—and probably also nonhuman—behavior is that substances are taken for a certain purpose, such as to attain a particular psychological state, to enable some desired behavior, to look a particular way, thus generally to achieve a desired aim. This has been called “drug instrumentalization” or “instrumental drug use” before (Müller, 2020; Müller & Schumann, 2011; Schleim, 2020). Some researchers even argue that substance use—particularly alcohol, caffeine, and tobacco—has played an important role in our biological and cultural evolution (Braidwood et al., 1953; Müller, 2020; Voigt & Katz, 1986; Wadley, 2016; Wadley & Hayden, 2015). For example, ensuring the availability of beer required humans to settle in a certain area and grow cereals. The final product was less perishable than other beverages, had a high nutritional value, and its effects may have served psychosocial needs in a particular cultural context. This question would be interesting to pursue further, but is not essential for our present purpose. After all, it does not follow from the fact that something was common in the past that it is permissible in the present as well. More importantly, we have already presented examples that illustrate how the status of substance use can switch—or rather be switched—back and forth, between normal, medical, and prohibited.

Treatment and enhancement are about instrumental use as well—and even more obviously so. In the former case, a substance is used to achieve or at least approach a state roughly understood as “health”, while in the latter the aim is to go even further, beyond normalcy. That the boundaries between these two categories are somewhat blurred—and perhaps even becoming increasingly fuzzy with the extension of “lifestyle medicine” and “lifestyle drugs” (Bodai et al., 2018; Flower, 2004; Gilbert et al., 2000; Rippe, 2013)—is a further reminder not to overstate the importance of these concepts. Nevertheless, essential distinctions used in drug policy have depended and still depend on drawing such boundaries. Speaking of “instrumental substance use” instead, thus even eschewing the complex and difficult notion of “drug”, has many advantages. It is a valid superordinate concept which covers a wide range of people’s behaviors without, however, communicating moral values. We will address values independently in the final section of this chapter.

First, we illuminate the new conceptual framework by discussing different goals that can be pursued with substances. What follows below should not be misunderstood as a “drug menu”. The book is intended only to inform its readers, not to encourage or discourage substance use. More comprehensive summaries of drugs, their effects, and side effects have been published before (e.g., Gage, 2021; Nutt, 2020; von Heyden et al., 2018). It should also be remembered that the way the substances work differs between people and usually depends not only on the dose, but also individual and contextual effects, such as users’ expectations and the reactions of other people (see Langlitz et al., 2021; Schleim, 2022a). Particularly when done excessively, substance use will cease to be instrumental and carry higher risks of adverse events and disease.

4.3.1 Instrumentalization Goals

One researcher who has focused on the reasons behind substance use for many years is Christian P. Müller, professor for addiction medicine at the University Hospital Erlangen in Southern Germany. Over the years, he has elaborated an approach called “drug instrumentalization theory” (Müller, 2020; Müller & Schumann, 2011). This allowed me to see cognitive or neuroenhancement in a new and more consistent way, integrated with substance use more generally (Schleim, 2020). Müller emphasizes the systematic and, one could also say, rational way in which many people instrumentalize substances to achieve certain goals. He distinguishes nine reasons, which we will briefly summarize below: (1) improved social interaction, (2) facilitation of sexual behavior, (3) improved cognitive performance/counteracting fatigue, (4) facilitation of recovery/coping with stress, (5) self-medication for psychological problems, (6) sensory curiosity, (7) euphoria, (8) improved physical appearance, and (9) facilitation of spiritual activities.

Importantly, the drugs’ effects are also considered dose-dependent, which means that they only enable the desired effects in a certain “dose window”, as pharmacologists call it. As we discussed in Chap. 3, there is, in particular, no “more is better” rule. By contrast, when exceeding an optimal amount, the effects of one and the same substance can shift from enhancement to impairment. This is often called the “inverted-u function”. For alcohol, for example, it is also hypothesized that lower or higher doses may affect different neurotransmitter systems in the brain, such as gamma-amino butyric acid (GABA) or glutamate (see Campbell et al., 2014). But we need not understand such details on the neurobiological level, where basic research is continuing to unravel the workings of even old substances such as alcohol or amphetamine.

Müller writes that alcohol, cannabis, and stimulants (e.g., caffeine, nicotine, cocaine, and the amphetamines, including MDMA/Ecstasy) can improve social interaction. Alcohol, for example, can help people deal with anxiety, discomfort, and inhibition in social contexts, which one might also simply call “shyness”. These effects usually require a low dose, while higher amounts are associated with increased impairments. Many of the stimulants are consumed at social events such as festivals or parties, partially to increase arousal and decrease fatigue. However, some of them are associated with aggression as well. Müller also points out that the same substances can facilitate sexual behavior, the second of the nine aims. This seems to be the case for establishing contact with someone, rather than the intercourse itself. After all, some substances can impair sexual functioning, particularly erection in men. Improving sexual behavior or the experience itself has previously been termed “pharmacosex” or “chemsex” (see Moyle et al., 2020).

The third goal is improving cognitive performance, which we discussed extensively in the previous chapter. In line with our conclusion, Müller writes that “there is little evidence for a significant increase in cognitive performance in a healthy individual with full mental capacity after any kind of psychoactive drug” (Müller, 2020, p. 5). However, he also notes that caffeine, nicotine, and other stimulants can compensate cognitive impairment associated with fatigue. This is closely related to the fourth aim: the facilitation of recovery and coping with stress. Here, Müller addresses alcohol, cannabis, cocaine, methamphetamine (“Crystal Meth”), barbiturates, and benzodiazepines. The last two are commonly prescribed for anxiety and sleeping problems.

Drug instrumentalization as self-medication, the fifth goal, is very complex: On the one hand, there is evidence that, as we have discussed above, substances are used to cope with psychological problems such as stress and anxiety, which in turn can be associated with a mental disorder. On the other hand, drug use can itself be a causal factor for mental disorders. Müller in particular discusses alcohol, nicotine, and cannabis—commonly used in many countries—and their relation to depression, post-traumatic stress disorder, and schizophrenia. For example, depression and alcohol dependence are frequently diagnosed together in clinical samples and “[i]n the majority of co-morbid cases, it appears that an established alcohol addiction may induce major depression” (ibid., p. 6). He also addresses the risk that people may eschew more efficient treatment because of self-medication. However, to what extent they use substances to cope with psychological problems below the threshold of clinical significance, how frequently they may take drugs to consciously or unconsciously deal with symptoms of a mental disorder, whether diagnosed or not, and how often the substance use itself causally contributes to the disorder has to be clarified better by further research.

Müller’s sixth and ninth aims are, in my view, better discussed together, as they are primarily about hallucinogenic drugs: People may use them to deal with boredom, out of curiosity, novelty seeking, or to have spiritual experiences and insights, as those described by William James (Box 4.2). Substances commonly taken for these purposes are mescaline, psilocybin, LSD, ketamine, GHB, and DMT. Müller points out that cannabis can also be used to “expand environmental and self-perception” and that MDMA “exerts hallucinogenic effects but also induces a unique feeling of ‘divine oneness’ with the world” (ibid., p. 7). Use of these substances, though, can also lead to risky behaviors or schizophrenia-like psychoses. The seventh aim of experiencing euphoria, hedonia, or a “high”, can be facilitated with alcohol, benzodiazepines, cannabis, LSD, and nicotine. The intensity of such states is described as higher with amphetamine, cocaine, heroin, MDMA, methamphetamine, methylphenidate (“Ritalin”), or morphine use.

The final aim, improved physical appearance and attractiveness, can be divided into a desire for a lean body, on the one hand, or a more muscular appearance, on the other. The former is described as more common among women, the latter among men. Stimulants such as amphetamine or cocaine are associated with attenuating hunger and weight loss. By contrast, anabolic steroids are used to gain more muscle mass (see Askew & Williams, 2021; Hope et al., 2021). Müller points out that steroids might also directly improve self-esteem and self-confidence, and not only indirectly through consumers’ increased satisfaction with their bodies (Müller, 2020).

4.3.2 Theoretical Reflection

Merely describing these possible uses implies neither endorsing nor disapproving of them. Elsewhere, I suggested that Müller’s nine categories could be reduced to four: (1) psychological activation/enhancement, (2) psychological dampening/relaxation, (3) new experiences, and (4) body shaping (Schleim, 2022b). Müller’s more comprehensive list has the advantage of illustrating more practical examples of instrumental substance use. I would argue that my condensed categorization allows us to better understand the psychology behind it. The first two amount to obtaining more of a desired psychological state or process (e.g., more attention) or less of an undesired one (e.g., anxiety). The third is orthogonal to this positive/negative distinction in two ways, as psychedelic experiences do not merely offer a greater or lesser sense of what is present, but something genuinely new—and this can be perceived as positive (e.g., “new insights” about oneself) or negative (e.g., a “horror trip”). Finally, changing one’s physical appearance is different from changing one’s psychological processes.

Yet, as has been emphasized so often in the book already, we should not overvalue the meaning of this conceptual distinction. After all, less fatigue could also mean more attention, and vice versa; gaining new insights might make one feel happier or depressed; feeling better might enable one to live in a healthier way, which could also improve one’s physical appearance; and having the leaner or more muscular body one desires so much may increase one’s satisfaction and self-confidence. But merely saying that the psychological and physiological domains, or that enhancement and impairment are related—that more or less everything is associated with anything—would not increase our understanding. The nine, or only four categories, are thus, once more, a pragmatic way to make sense of something, in this case substance use. How we perceive it also depends on the perspective we take.

Those readers who are already primarily informed about drug harms might find it difficult to accept the notion of instrumental substance use. However, repeating a question from the previous chapter: Why would users use the substances, if that’s of no use? Others may recognize their own consumption patterns in the goals described above. However, for yet others it might just be a confirmation of what they have long known about drugs. It goes without saying that substance use may have unwanted side effects, but the same holds for medical drugs and—depending on the amount ingested—even beverages and food. In his conclusion, Müller emphasizes again the importance of finding the right dose window for instrumental use to keep benefits and risks in a reasonable balance (Müller, 2020). In line with what we have argued in Chap. 2, only a minority of substance users become addicted, while those engaging in instrumental consumption can use checklists to identify problematic patterns.

Müller also addresses the risk of overinstrumentalization: Imagine someone drinking alcohol or smoking cannabis in the evening to deal with work-related stress. This substance use may help the person to relax and in turn to feel and work better the next day. However, if they then increase their workload knowing that the unwanted effects can be dealt with, the amount of stress might increase, which may in turn require the person to consume more of the substance to gain the desired result. Higher doses increase the risks of adaptation, dependence, side effects, and disease. This illustrates the reasonable boundaries of instrumental substance use and also the biopsychosocial context in which it occurs, with someone’s decision (psychology) having repercussions on the body (biology) and circumstances (society), which all interact with each other.

While some scholars see instrumental substance use as a part of human nature and welcome opportunities to make more of one’s life (e.g., Miller, 2011), others point to the risk of excessive individualization (e.g., Schleim, 2014; Wu, 2011). Imagine that employers coerce employees to use substances in order to increase performance in an already-highly productive and competitive context. David Nutt mentioned a real example from the Soviet era, where stimulant drugs were used in factories to enhance workers’ output (Nutt, 2020). Increased competition among truck drivers during America’s “first amphetamine epidemic”, as Nicolas Rasmussen called it, may be another example (Rasmussen, 2008). This reminds us of the puzzle posed at the beginning of Chap. 3: At an already-enhanced level, the same question of whether even higher performance would be better comes up again. Instrumental substance use can thus get us only so far. At some point, we would have to concede a limit to prevent serious damage to body and mind. These thoughts anticipate the discussion of values in the final section of this chapter.

4.4 Values

Thus far, we have focused on understanding the problems, the scholarly debate, and the scientific facts related to health, mental health, enhancement, and substance use. In Chap. 3, we saw that issues concerning safety, coercion, and fairness have been frequently addressed by ethicists. However, merely describing these does not answer the question of whether instrumental substance use should be generally permissible in society or whether one should do it. Even a logical or mathematical proof depends on the axioms and assumptions one makes. In ethical matters, we have to deal with even less certainty. What provides us with some guidance is the identification of different positions and values that are relevant to our present topic. One source of information is a closely related academic debate that occurred in the 1970s, decades before scholars began talking about “neuroenhancement” or “instrumental substance use”.⁸

American psychiatrist Gerald Klerman (1928–1992), who was a professor at Harvard University and later director of a prominent drug prevention program under US president Jimmy Carter, suggested several useful terms in the discussion, opposing “psychotropic hedonism” to “pharmacological Calvinism” (Klerman, 1970, 1972). The latter reflects the Protestant work ethic, which can be summarized as “No pain, no gain”. Psychotropic hedonism, by contrast, focuses on the now: “Why wait when I can fulfill my needs and achieve my goals now, if necessary, by pharmacological means?”

At the time, however, the renowned American medical ethicist Robert M. Veatch (1939–2020), who would later become professor at Georgetown University in Washington, D.C. and researcher at the Kennedy Institute of Ethics, criticized Klerman’s explanation as being overly simplistic (Veatch, 1977). Drawing on Max Weber’s (1864–1920) analysis of the Protestant work ethic (Weber, 1905), he concluded that substance use to increase efficiency could be permissible from a Christian perspective. However, advocates of an ethic that is based on the “wisdom of nature” and is critical of artificial interventions into the body would be particularly opposed to this.

Klerman’s psychotropic hedonism most closely corresponds to what Veatch called a “Protean ethic”, which is named after Proteus, the Greek god of rivers and oceanic bodies of water, who was able to change his form. In this view, substances are used to perpetually change and to adapt to external demands. Proponents of this ethic deny the existence of a permanent essence of human beings. Today, these ideas from the 1970s resemble precursors of globalization, competitive pressure, and life-long learning. Klerman and Veatch did agree on one thing, however—that social values are articulated in the way people treat substances. These values, according to Klerman, create divisions between different social groups: the old and the young, the more and the less educated, the poor and the rich, and groups with different religious or cultural backgrounds (Klerman, 1970). Here, the psychiatrist lamented that they lacked a suitable word for nonmedical substance use:

In our society there is no suitable label for the use of drugs to enhance pleasure or performance. It is sometimes called social drug use, but this term is not part of our scientific lexicon. […] The fact that we don’t have an established nomenclature for nontherapeutic drug use is in itself an indication of society’s conflict. (Klerman, 1970, p. 316)

In this respect, times have changed. As we have seen in Chap. 3, “cognitive” and “neuroenhancement” became popular terms in the early 2000s. However, according to the discussion in the present chapter, “instrumental substance use” would be a better alternative. Several goals were addressed in the previous section. Earlier in the book, we also found that distinctions between diseases/disorders, health/normalcy, and enhancement remain vague, even if there are many cases that can be assigned unambiguously to only one of the categories. But if health is now understood as the ability to adapt and to self-manage (Huber et al., 2011), if renowned professors advising governments emphasize the importance of maximizing one’s “mental capital” (Beddington et al., 2008), if other professors from elite universities call the consumption of legally prohibited stimulants to improve one’s cognitive performance “responsible use” under certain conditions (Greely et al., 2008), and if many people are using substances instrumentally anyway, how much sense does it make to prohibit and criminalize this behavior?

Indeed, in line with the Protean ethic, some scholars have described instrumental substance use as “self-improvement” (Askew & Williams, 2021) or “competitive entrepreneurialism” in the context of “neoliberalism” (Mann, 2021). Miller and Müller wholeheartedly welcomed the possibilities of using substances to adapt to the demands of a certain environment (Miller, 2011; Müller, 2020; Müller & Schumann, 2011). But should adaptation be limitless? How far might coercion go before too much autonomy (literally, having one’s own laws) is lost and heteronomy (having others’ laws) reigns? Aren’t we already very productive and isn’t this high level of productivity already causing severe damage to life and the environment on planet earth? Doesn’t Wu have a point when he emphasizes the risks of too much individualization (Wu, 2011)? And isn’t Inon’s critique valid when he points out that people’s emotional responses in competitive environments also tell us something about these environments, not just the people (Inon, 2019)?

The argument from the perspective of evolution suggested that instrumental substance use was common and normal, probably even advantageous in our past (Braidwood et al., 1953; Voigt & Katz, 1986; Wadley, 2016; Wadley & Hayden, 2015). But it does not follow from this alone that it is still morally the right thing to do in the present and future. There is also an essential difference between an adaptation that increases the chances of survival in the face of natural hardship and one that is a response to unequal human-made social structures. In the latter case, the debate also needs to address the political foundations of living together. That the pressure to engage in instrumental substance use is particularly strong under the extraordinary conditions found in professional sports and warfare (see Nutt, 2020) also raises the question of whether this is the right model for society at large.

In times of peace and when survival is not at risk, other values—such as autonomy, distributive justice, social participation, and sustainability—should at least be considered alongside performance enhancement. Above all, we should also recall that cognitive improvement might have a lower priority in society at large than it does among professors in scholarly debates (Schleim, 2014). As we have seen in Chap. 3, even their own students seem to think differently about the importance of substance use to enhance performance.