Brain Steroids: Ethical Concerns Regarding Cosmetic Neurology and Psychopharmacology
By GENNADIY KATSEVMAN
ABSTRACT: Advancements in the field of medicine have created several novel ethical concerns. Developments in neuroscience, for example, have resulted in the creation of a new field called “neuroethics.” This paper addresses the neuroethical issue of psychopharmacological enhancement; should society have rules against psychopharmacological enhancement or “brain steroids,” particularly in academia? If so, on what guidelines should the rules be based? I argue that there should be no major restrictions against enhancement itself, although drugs that are blatantly harmful should be prohibited as with therapeutic drugs. In Part One, I provide arguments in favor of psychopharmacological enhancement. In Part Two, I describe and refute arguments against such enhancement. Finally, in Part Three, I provide some conclusions regarding psychopharmacological enhancement and brain science in general.
Consider the following examples:
- You are an undergraduate student aspiring to go to medical school. You have been studying for the MCAT for the last 3 months of summer, grinding for eight hours per day. The test day finally comes, and you do well and score 30 out of 45. Your friend, meanwhile, has been enjoying his summer—going to the pool, to the beach, and hardly studying. Four weeks before the exam, however, he started taking a new pill, with no known side effects, that improved his attention and short term memory. His big day came and he scored a 33.
- You have discovered that your spouse has just been diagnosed with a brain tumor. Surgery is very risky with minimal chances of survival. Two doctors in the area are willing to perform the surgery. Your friend from college is one of the surgeons. He tells you that he has been taking the same pills throughout medical school and even takes them now during surgeries—they improve his memory, concentration and focus, and reduce the natural tremor of the hands (effect proven through research trials). The other doctor that is willing to do the surgery is “normal” and refuses to take such a drug due to his desire to be “natural.” Which surgeon do you pick?
Most people have a different emotional response to the same person of each scenario. Many would view the friend in example one as “cheating” or taking the “easy way out” without putting in effort; they would be against the friend using the enhancement pill because it is “unfair.” In the second scenario, however, most people would side with that same “cheater” and would effectively choose the friend surgeon to operate since he improves the chances of the spouse’s survival. What is the difference between the two situations?
These examples raise a variety of difficult ethical questions in relation to the emerging field of psychopharmacology. As Walter Gannon writes in Defining Right and Wrong in Brain Science, “the oldest and most difficult of these questions is how to weight the potential benefits of psychotropic drugs against the risks (233). Since the brain is the most complex and least understood organ in the body, “there may be unforeseen adverse effects of altering neurons and neural systems” (233). Many “psychotropic drugs can have both positive and negative effects on the brain and mind” (233). Although the “general aim of psychopharmacological intervention in the brain is to restore dysfunctional systems responsible for psychiatric or neurological disorders,” many techniques are being used to enhance already normal brain function (233). Currently, “a number of pharmaceutical and nutritional supplement companies are interested in selling drugs that…allow individuals to go without sleep for longer periods of time than they otherwise could or herbal substances that allegedly improve memory” (Caplan, 272). Scientists realize that “a drug capable of helping an Alzheimer’s patient retain memory function might also provide some enhancement to those who simply have poor memory skills and that the market possibilities for selling a drug such as a memory enhancer are huge” (Caplan, 272). Many students, for example, “are keenly interested in any drug that might improve their ability on tests or in musical, dramatic, or athletic performances by allowing for increased short-term memory, greater attention span, or reduced anxiety” (Caplan, 273).
Should society have rules against psychopharmacological enhancement, particularly in academia? If so, on what should the rules be based? I will argue that there should be no major restrictions against enhancement itself, although drugs that are blatantly harmful (e.g., death or serious injury) should be prohibited as with therapeutic drugs. In Part One, I will provide arguments in favor of psychopharmacological enhancement. In Part Two, I will describe and refute arguments against such enhancement. Finally, in Part Three, I provide some conclusions and final thoughts about psychopharmacological enhancement and brain science in general.
I. Arguments for the Use of Psychopharmacological Enhancement
Psychopharmacology has always had great potential. As Martha Farah states in Emerging Ethical Issues in Neuroscience, “the enhancement potential of some psychiatric treatments is, in itself, nothing new” (20). In reality, pharmacological enhancement has begun and “is arguably being practiced now in several psychological domains: enhancement of mood, cognition, and vegetative functions, including sleep, appetite, and sex (20). Of special interest are the manipulations that “alter cognitive abilities, including attention and memory” (22). Attention includes “active use of working memory, executive function, and other forms of cognitive control” (Farah & Wolpe, 50). It also includes sustained effort and resistance to distraction and is “primarily modulated by dopamine and norepinephrine” (Farah, 22). In addition to providing a therapeutic effect for children with ADHD, stimulants, such as Adderall and Ritalin may induce cognitive changes in normal individuals: they may enhance “vigilance, response time, and higher cognitive functions, such as novel problem solving and planning”—an effect many healthy individuals have discovered and are utilizing. (Farah, 22). In some school districts “the proportion of boys taking [Ritalin even] exceeds the most generous estimates of ADHD prevalence” (Farah & Wolpe, 50). Meanwhile, current advances in neuroscience are paving a variety of new therapeutic techniques to fight dementia or Alzheimer’s disease. Although they are developed to treat memory-related disorders, “many of them will be put to use—and will be efficacious—in people who are not ill,” proving to be of special interest to normal people (Ackerman, 77). One drug specifically developed to treat narcolepsy, for example, can actually “prolong alert wakefulness for days” (Farah, 23). Recognizing the “desire of most people for quicker, sharper, and more reliable memories,” many researchers are “explicitly pursuing drugs or pharmacological agents that might improve our ‘normal’ capacity to remember, that might enhance the cognitive performance of both underachievers…and overachievers, and that might prevent, halt, or reverse age-related memory decline” (President’s Council on Bioethics, 237-8).
So what is the problem if college students use Adderall to study for the MCAT? They are, in effect, improving their cognitive functions. Such drugs can be beneficial for a person’s individual well-being. He/she will become more attentive with greater memory functions; “memory enhancement could benefit individuals by enabling them to access a broader base of factual and conceptual information, as well as to process this information more effectively in decision making and other cognitive tasks” (Glannon, 265). This may help him/her to be more capable, to reach specific goals in life, and to overall live a happy and successful life.
Psychopharmacology may also be seen as advantageous for the well-being of the community and for the public good. Students and individuals may become better, more attentive citizens, engineers, doctors, and lawyers; society as a whole may benefit. Doctors that are more attentive and alert may save more lives; scientists that can stay awake longer may have more breakthroughs. Humanity is always trying to move forward and improve, and this is certainly one way of improving humanity, the quality of life, and the standard of living.
There is also the issue of autonomy and individual right. It would appear to be an infringement on personal freedom to restrict access to safe enhancements (if they are too risky, however, it may by interpreted as beneficence). If a free individual decides to tamper with his/her own brain, it should be generally allowed. After all, that brain is the property of that person. If a person wants to and is allowed to tamper with and augment breast size, why can’t a person be allowed to augment his/her brain?
II. Arguments against the Use of Psychopharmacological Enhancement and Refutations
Despite all the aforementioned benefits of psychopharmacology, there still seems to be “something wrong” with it. As Farah writes, “most of us would love to go through life cheerful and svelte, focusing like a laser beam at work and enjoying rapturous sex each night” (24). Yet most people “also feel uneasy about the idea of achieving these things through drugs” (24). What can this gut feeling be attributed to?
The first potential problem that springs up is the “possibility of serious side effects for the individual, including long-term or delayed effects that might evade current FDA safeguards” (Farah, 24). Even more risky is the “off-label use” or the use of drugs for “purposes for which [they] were not originally designed and for which they did not initially receive FDA approval” (Gannon, 233). If allowed, will psychopharmacology be detrimental to the well-being of the individual? After all, this neuroscience-based enhancements intervene “in a far more complex system,” the brain, than other enhancements for the body (Farah & Wolpe, 52). As a result, we are “at greater risk of unanticipated problems when we tinker” (Farah & Wolpe, 52). A young, ambitious pre-medical student may get into Harvard Medical School and attain a prestigious job thanks to enhancement. He may also get a chance to save many lives and benefit society. However, this early success may unfortunately be followed by a “middle-age of premature memory loss and cognitive decline” (Farah, 22). If the enhancement drugs are taken at too early of an age, they may have some detrimental effects: “empirically, prodigious memory is linked to difficulties with thinking and problems solving, and computationally, boosting the durability of individual memories decreases the ability to generalize” (23). Would “endowing learners with super-memory interfere with their ability to understand what they have learned and relate it to other knowledge” (Farah & Wolpe, 52)? It appears that “normal forgetting rates may even “be optimal for information retrieval” (Farah, 25). In other words, if you remember too much or if you have too much clutter stored, you might have difficulty retrieving specific information. That is part of the reason why interest in memory enhancement has thus far just “been confined to the middle-aged and elderly, whose memory ability undergoes gradual decline in the absence of dementia,” even when healthy (Farah 23; Farah & Wolpe, 50). Although “few consider memory enhancement for the young to be a goal,” it is still important to consider the possible ethical implications. Drugs aimed at enhancing attention, however, can be aimed at children or young adults.
Despite all the recent advances, still very little is known about the complex brain and even less is known regarding which limitations “are there for good reason” (Farah, 22). From an evolutionary standpoint, there might be “hidden costs” to enhancement; since we “understand little about the design constraints that were being satisfied in the process of creating a modern human brain,” we do not know “which ‘limitations’ are there purposefully” (Farah, 24). Walter Glannon echoes this idea and states that “the limits we have in our capacity to remember only so many facts or events may be part of a natural design that is critical for our survival” (266). Sometimes forgetfulness is beneficial and allows a human being to cope with stressful or traumatic experiences (in addition to the aforementioned effect of improving ability to retrieve information, generalize, and problem solve in kids). If a person lives and intensely remembers all the bad that has happened, he/she would be constantly tormented.
The brain remains to be “the most complex organ we possess;” no other system “has so many roles and consists of so many interoperating parts” (Leshner, 76). This “interconnectedness of its parts and the multitasking nature of [the brain’s] individual structures means that any intervention, however small or precise we try to make it, is unlikely to have a single consequence” (Leshner, 76). Cognitive functioning, for example, is part of an “interconnected system in the mind” that involves emotional processing so “trying to enhance cognitive processing could impair emotional processing,” making an individual indifferent and unable to experience life’s pleasures (Glannon, 268). Altering the brain may have several other effects in other areas, some that we cannot even imagine today.
None of these potential risks to the individual, however, warrant complete restriction on the use of pharmacological enhancement, although it is true that long-term consequences have not been fully investigated. It is possible that the long-term effects will not be known for a long time since clinical trials are very slow and expensive—is it worth waiting to find out the possible effects (if any)? This involves potentially great cost-benefit tradeoffs. Furthermore, “a concern with long-term or hidden side effects is not unique to enhancement but applies to therapeutic treatments as well” (Farah, 24). That implies that psychopharmacological treatments for dementia, Alzheimer’s, or narcolepsy would all have to be outlawed. In reality, “drug safety testing does not routinely address long-term use, and relatively little evidence is available on long-term use by healthy subjects” (Farah & Wolpe, 52). It is important to note, however, that “although safety is a concern with all medications and procedures,” our “tolerance for risk is smallest when the treatment is purely elective” or is for enhancement purposes (Farah et al., 294). Different people will also be willing to take different degrees of risk to achieve the enhancement they desire.
Short-term consequences, on the other hand, are being studied and it is possible to counteract and prevent them through the use of other drugs. Psychopharmacology has always been considered for enhancement but hardly implemented solely for the reason of safety. The enhancement aspect has remained the same but what has changed is the side effect and risk aspect of the treatments: “with our growing understanding of neurotransmission at a molecular level, it has been possible to design more selective drugs with better side-effect profiles” (Farah, 20). Prozac actually belongs to a class of drugs named “SSRI” in which the first letter stands for “selective” (Farah & Wolpe, 47). Farah states that “adjuvant therapy with other drugs is increasingly used to counteract the remaining side effects” (20). The result of both new and adjuvant drugs is the same: “increasingly selective alteration of our mental states and abilities through neurochemical intervention, with correspondingly less downside to their use by anyone, sick or well” (Farah & Wolpe, 48). It is important to keep in mind that even “normal” drugs against illnesses or disorders have side effects; anti-depressants may even increase the risk of suicidality in young adults or children yet these drugs are not restricted (Leon, 1787). Similarly, psychopharmacologically-enhancing drugs should not be prohibited. However, people do need to be educated and informed about the possible side effects so that they can make informed risk-benefit analyses, decide which risks are “acceptable in view of a drug’s benefits,” and determine whether to take the drugs or not (Farah et al., 295). Of course, more research is necessary to determine all the possible risks. Contrary to popular belief, however, Farah and Wolpe state that so far, medications and stimulants “have good safety accords, and their long-term effects may even be positive” (52).
Paul M. Matthews states in Transforming Drug Development Through Brain Imaging that novel testing techniques in the future, including brain imaging, may speed up the long, tedious, and expensive process that entails “develop[ing] a compound, test[ing] it in the laboratory and then in clinical trials, and finally obtain[ing] approval for it as a new drug” (153). A faster process may result in more drugs being more thoroughly tested and may, in effect, reduce the amount of negative side-effects, making more drugs safer and more efficient. However, as Henry T. Greely states in Knowing Sin: Making Sure Good Science Doesn’t Go Bad, we cannot make “prinum non nocere, ‘first do no harm,’ a binding obligation” since too often harm will occur” and inevitably does (93). Nonetheless, “doing no harm can be an inspiration” and researchers and physicians still need to “think about the ethical, social and legal consequences of [their] work” so that enhancement medicine, for example, does not become riddled with negative side effects, whether they be physiological, social, or ethical in nature.
The third main argument against psychopharmacological enhancement in academia stems from potential harm to society if use becomes widespread. There are worries that these enhancements or drugs will not be fairly distributed or may create more separation between the classes. As Donald Kennedy states in Neuroscience and Neuroethics, “perhaps it is our belief that the playing field should be level—we worry about the students who can’t access the drug” (59). It is “likely that wealthy and privileged will have the choice of self-enhancement and the less privileged will not” (Farah, 25). Ritalin use by normal healthy people, for example, ís highest among college students, an overwhelmingly middle-class and privileged segment of the population” (Farah et al., 295). There will be “cost barriers to legal neurocognitive enhancement and possibly social barriers as well for certain groups” (295). Others in opposition to neurological enhancement are concerned that allowing such enhancements to be undertaken will result in higher levels of normalcy that will put others—those who choose not to enhance or those who cannot choose to enhance, including the poor—at a disadvantage. This, in effect, would be a form of indirect coercion. “Employers will recognize the benefits of a more attentive and less forgetful workforce” while “teachers will find enhanced pupils more receptive to learning” (Farah et al., 295). Merely competing against “enhanced coworkers or students exerts an incentive to use neurocognitive enhancement,” whether it be to keep a job or stay in school (Farah et al., 295). As Chatterjee points out in The Promise and Predicament of Cosmetic Neurology, some people might be coerced “to make use of every possible advantage, including enhancements, just to stay in place” (307).
If these are seen as potential harms that justify prohibition, then many other activities that are normally accepted should be restricted also. As Farah states, “our society is already full of such inequities” and unequal access itself “is generally not grounds for prohibiting neurocognitive enhancement, any more than it is grounds for prohibiting other types of enhancement, such as private tutoring or cosmetic surgery, that are enjoyed mainly by the wealthy” (Farah, 25; Farah et al., 296). Kennedy echoes this response by asking “what about the kids who can’t afford a preparatory course for taking a standardized test” (59). MCAT classes are certainly not evenly distributed at a price of almost $2,000, yet they are still allowed. What differentiates MCAT classes from a pill if “both raise the same questions about distributive justice” (Kennedy, 59)? Both seek to enhance cognitive functions and both can be successful; “the brain makes no distinction between psychopharmacology and experience” since both are able to cause physical changes in the brain (Ackerman, 57).
Nobody seeks to “prohibit private schools, personal trainers, or cosmetic surgery on the grounds that they are inequitably distributed” (Farah, 25). If anything, these activities stem from our capitalistic society; some people get ahead, pursue, and hope to attain further opportunities to excel. Moreover, in the United States, “wide disparities in access to and quality of health care and education are tolerated” (Chatterjee, 306). If such atrocities are tolerated and if there is unequal access to these “life enhancers,” how is pharmacological enhancement any different?
Also, consider the alternate to the idea of coercion of the poor: people living in poverty may choose to spend their money on these drugs in an attempt to get out of poverty; “in principle there is no reason that neurocognitive enhancement could not help to equalize that opportunity in our society” (Farah et al., 296). In comparison with other forms of enhancement, from good nutrition to high-quality schools, “neurocognitive enhancement could prove easier to distribute equitably” (Farah et al., 296). If these drugs succeed in increasing memory and performance in school, this might be “the way out” of poverty. As Walter Glannon states in Psychopharmacology and Memory, memory enhancement “could promote greater opportunity for individuals to have better education and more lucrative employment” (265). Janet Radcliffe Richards had a similar argument against those who believe organ transplants exploit the poor which I adapt to psychopharmacological enhancement: “as we contemplate with satisfaction our rapid moves to…protect the poor, we leave behind one trail of people who [simply want to enhance], and another of people desperate [and willing enough to take the medications to get out of poverty]” (533). This intervention thus seems “in direct conflict with all our usual concerns for life, liberty, and the pursuit of happiness” (533).
Radcliffe further states that “coercion is a matter of reducing the range of options there would otherwise be;” in other words, coercers come and take away options until the best available is the one they want (535). Offering enhancement medicine for academic purposes, however, does not restrict the range of options; it actually may provide a vehicle to get out of that poverty. Even if the widespread use of enhancement drugs does serve as an act of coercion on the non-poor, it would be as “much of an infringement on personal freedom to restrict access to safe enhancements for the sake of avoiding the indirect coercion of individuals who do not wish to partake”(26). It is also worthwhile to “consider a scenario in which the entire populace is given full and equal access to Ritalin, Prozak, and other enhancers” (Farah, 25). Even if the drugs are proven to be completely safe, most people would still feel uneasiness, so it is more than likely that their “qualms about enhancement” are not linked to equal opportunity (Farah, 25).
The final concerns regarding psychopharmacological enhancement in academia stem from the belief that it goes against some widely-shared intuitions. This group of concerns results “from the many ways in which neuroscience-based enhancement intersects with out understanding of what it means to be a person, to be healthy and whole, to do meaningful work, and to value human life in all its imperfections” (Farah & Wolpe, 52). First, “brain steroids” lead to the moral objection to “gain without pain.” As the common saying “no pain, no gain” demonstrates, most people in our society “feel that there is value to earning one’s happiness, success, and so on” and that “accomplishments in life are made meaningful partly by the efforts they require” (Farah, 25; Farah & Wolpe, 53). Some argue that engineered improvements in performance, however, “are not authentic, not earned, and therefore not morally commendable” (Caplan, 273). Enhancement may be seen as a “moral shortcut” that “undermines the natural development of the human being to become self-reliant and to overcome obstacles” (Ackerman, 16, 57). If a student takes Adderall to study for the MCAT, it might be interpreted as “cheating,” “taking the easy way out, and lacking dignity or value;” Adderall enables him/her to study for less time and absorb about the same amount of material. Enhancement as a whole may reduce the effort needed for personal accomplishment.
Although people “recognize the value of earning life’s rewards, our lives are [still] full of shortcuts to looking and feeling better” (Farah, 25). For example, “we do not disapprove of people who dislike vegetables improving their health by taking vitamin pills” (25). “Nor do we begrudge” medical school applicants their MCAT books or Kaplan classes (25). As Farah states, psychopharmacological enhancement “can therefore be seen as fitting in with an array of practices that are already accepted and widespread” (25). Although it does feel exciting to achieve our goals after testing our limits and “striving, struggling, and working to overcome innate boundaries,” it is also “very satisfying to have benefits that simply come from out of the blue or through good fortune” (Caplan, 275). Life is full of those pleasures and, consequently, “we do not always have to ‘earn’ our happiness to be really and truly happy” (Caplan, 275). Even if the “no pain, no gain” idea was held up, it would be difficult to determine “who decides which pains should be suffered to build character and which can be reasonably avoided,” something that would be necessary to transform this concern into public policy (Chatterjee, 306).
Some proponents of restriction on enhancement in academia argue that “the happiness or satisfaction achieved through engineering is seductive and will lead to a deformation of our character and spirit” (Caplan, 273). They also state that “to accept enhancement for our children will undermine and deform the role of the parent” (Caplan, 273). The President’s Council argued that enhancement will “distort or deform our character” and asked this question: “why would one need to discipline one’s passions, refine one’s sentiments, and cultivate one’s virtues—in short, to organize one’s soul for action in the world—when one’s aspirations to happiness could be satisfied by drugs in a quick, consistent, and cost-effective manner” (Caplan, 273)? In essence, if we enhanced ourselves and “our achievements and enjoyments came easy, why would we continue striving to be good and virtuous people” (Caplan, 274)? These critics seem to appeal to virtue ethics, claiming that through the use of enhancement, people will cease to desire to be good, honorable, hard-working individuals with good traits of character. Furthermore, if people “seek to perfect” their children through enhancement, the kids will no longer be seen as “gifts”–now possibly an appeal to religious ethics—and the parents may not be taught humility or be as “open to the unbidden” (Caplan, 276)
This argument, however, falls short in many aspects. As previously mentioned, there are already many people taking shortcuts—not necessarily neurological—that may be looked down upon but aren’t. In fact, we “generally encourage innovations that save time and effort, because they enable use to be more productive and to direct our efforts toward potentially more worthy goals” (Farah et al., 296). In addition, “laying the blame for vice at the foot of enhancement ignores the inconvenient fact that the desires for quick returns, easy money, and instant gratification have nothing at all to do with enhancement” (Caplan, 274). Instead, they are “traits of many, if not most, human beings” (Caplan, 274). Even if enhancement is prohibited, individuals will probably still desire to “cheat” or take “shortcuts.” If children cannot take a pill to focus and memorize more for the test, they just might look over and copy someone else’s answers. Just because a person is enhanced with a better attention span or memory does not mean he/she will not be ready for challenges in the real world or will be “weak and spineless” (Caplan, 274). These characteristics are innate and improving performance “is not necessarily toxic to virtue” (Caplan, 274). Regarding the enhancement of children, a parent “can accept a gift, embellish, tweak, noodle, and modify it in order to improve it, and still cherish what was given as a gift” (Caplan, 276). It should not be necessary to accept a “random draw of the genetic library” or accept a “random point mutation” simply to learn to value and “abide the unexpected” (Caplan, 276). Overall, “should the state be allowed to interfere in how parents choose to raise their children” (Greely, 92)? In our free, capitalistic society, many believe that “it is their right to do whatever they can to minimize their distress and maximize their achievement. They may believe it is their duty to give their children every advantage” (Ackerman, 62).
Since psychopharmacology changes brain function and the brain is generally associated with the “self,” other pro-restriction arguments state that such drugs would undermine the commonly held idea that “persons endure over time” (Farah & Wolpe, 53). Although some of their characteristics may change, “there is a self that remains constant for as long as the person can be said to exist” (Farah & Wolpe, 53). What makes the brain so special “is that it is the seat of the mind;” it is the “essence of the ‘self’ and, therefore, “altering how a person’s brain works may be altering who that person is” and his/her essential being” (Leshner, 76; Gannon, 233). If you change your brain and mind, are you actually changing yourself and your personhood? Since the brain is the final common path for the experience and expression of mental activity, “any intervention in our brains raises the specter of not only causing potential physical disability but also changing our cognition, emotion, or even our personalities” (Leshner, 76). Some people thus argue that “the changing of abilities, memories, and mood at will by swallowing a pill may undermine the idea of a constant ‘self’” and, consequently, is wrong (Farah & Wolpe, 53).
A similar objection to such enhancement stems from the Natural Law theory. Altering brain structure and function, specifically for enhancement purposes, is not natural (it is, after all, an enhancement of the human condition). The same issue arises with other types of enhancement. Gregory Pence mentions in Re-Creating Medicine how in medicine today, “many naysayers warn that we must accept natural limits…that we are too materialistic…that we are narcissistic in wanting better bodies than we inherited…and that all the above show our warped priorities” (161). This line of thought opposes enhancements of the mind and body and considers improvements improper.
After further investigation, however, this argument falls short of justifying restriction on psychopharmacological drugs in academia. There are plenty of current practices that are similarly unnatural and change the self and personhood. If drugs that alter the brain and, in effect, alter the self should be prohibited, then anti-depressants, for example, should be outlawed since they also change the self (from a depressed individual to a happier individual). That treatment, however, can be argued as therapy to normalize a “deviation” so another example is necessary. Martha Farah and Paul Root Wolpe in Monitoring and Manipulating Brain Function state that “the attempts of human beings to use chemical substances to alter normal affective and cognitive traits is as old as the drinking of alcohol” (48). Shouldn’t alcohol be prohibited if it temporarily changes the self, making some individuals polar opposites from their normal, sober selves? There are also a plethora of other procedures being done that are not natural. Consider “cosmetic surgery and the use of human growth hormone for healthy children who are naturally short” (Farah & Wolpe, 51). Although they do not specifically affect brain function as do psychopharmacological drugs, they are nonetheless enhancements that are generally accepted. Is laser eye surgery, a procedure that “sometimes can give eyes better than 20-20 vision” immoral or wrong (Caplan, 271)? Caffeine can also act as a stimulant (and some people do indeed use it for academic purposes) yet it is not prohibited. Meditation, tutoring, and psychotherapy are all enhancement techniques, although non-neuroscience-based, that affect brain function and the person yet are not seen as objectionable (in fact, these are “often seen as laudable”) (Farah & Wolpe, 52).
Further opposition to enhancement states that maximizing performance of healthy individuals through such drugs is in a sense commodifying human abilities. A commonly shared intuition is that “persons have a kind of value that is independent of any commodity or capability they bring to the world”—Kantian ethics (Farah & Wolpe, 53). People have value “independent of how well they do what they do” (Ackerman 81). We do not value a spouse or a child “because of how well he or she performs,” like we would a car. We value them “because of some essence of their personhood that we care about—the very essence that we instinctively feel comes under threat of distortion or replacement whenever a medical intervention touches the brain” (Ackerman, 81). By taking the drug and altering our neurochemistry, it is almost as if we are improving our performance and abilities “the way we would improve the performance of a car, opining the hood and going in and tinkering” (Ackerman, 81). Psychopharmacological drugs can indeed maximize the performance of an already healthy, functional person and this “can be viewed as commodifying human abilities” (53).
This idea is again contradicted by the number of other practices that similarly commodify human abilities; it is not simply “unique to Ritalin-enhanced executive ability” (Farah et al., 297). It is probably more baldly on display “in books and classes that are designed to prepare preschoolers for precocious reading, music, or foreign language skills, but many loving parents seek out such enrichment for their children” (Farah et al., 297). If such activities are not prohibited based upon the idea that they “commodify” human abilities, then there is no reason to justify the restriction of enhancement psychopharmacology.
III. Conclusions & Final Thoughts
Although some of the arguments against brain enhancement are valid, I do not believe they are sufficient to restrict the use of enhancing psychopharmacological drugs in academia. As Arthur Caplan states in Staining their Brains: Why the Case Against Enhancement is Not Persuasive, “each argument carries some emotive force but is not a sound basis for rejecting choices that individuals might make to improve or optimize themselves or their children” (273). It is true that there “may be unforeseen adverse effects of chronically altering brain circuits with psychotropic drugs” but I believe it is up to the individual to “weigh their short-term benefits against their long-term risks” (Gannon, xvi). It will be up to the person to decide whether “the benefits of performing better on exams or having better memory [is] worth any risk to other mental functions” (Gannon, xvi). Nonetheless, these concerns do not warrant restriction. William Safire in Visions for a New Field of ‘Neuroethics’ asks “what is there to stop us from using such a ‘Botox for the brain’” to make a person more “intellectually attractive” (10)? I believe the only factor that will warrant restriction has to do with safety; only if studies show a severe and dangerous correlational or causative effect of the drugs on the body or brain, will restriction on that particular drug be enforced. Restriction on enhancement in academia itself, however, will not come to fruition.
From a practical viewpoint, it would be hard to regulate psychopharmacological enhancement in academia (for example, to prevent “cheating”). Millions of prescriptions are written every year for drugs that act on the brain yet, as Sandra Ackerman writes in Hard Choices, Hard Choices, “it is startling to remember that there are no objective tests for mental disorders” (55). Farah states in Emerging Ethical Issues in Neuroscience that “the line between healthy and sick is a fuzzy and perhaps arbitrary one” (21). It will be difficult to distinguish between kids with ADHD who need stimulant medication for therapy and normal, healthy kids who might want it for enhancement: “as with affective disorders, it is difficult to locate a discontinuity between normal attentional functioning and ADHD (22). If doctors intervene too “high up” on the continuum, they would be practicing enhancement. Farah even states that “pharmacological enhancement of children’s attention is routine in some communities” (22). Parents are eager to “give their children every edge in school” and “press their pediatricians for medications” (22). Teachers, meanwhile, “often welcome the greater orderliness in a classroom of attentive students” (22). And since ADHD in children is “diagnosed primarily on the basis of parent and teacher questionnaire responses, it can be difficult to free the diagnostic process from the values and standards of the respondents” (22). This difficulty to separate enhancement from therapy will make monitoring and restriction of psychopharmacological enhancement very difficult.
If a law was to be developed, what features would the “FDA take into account when weighing whether or not to approve a drug that might be taken by healthy people to augment or improve some aspect of themselves” (Ackerman, 59)? How sure can we truly be that the medicine is safe and how much benefit outweighs the risks? The safety criterion is an issue in itself since testing has to be done on healthy people who may just end up with getting sick. Whether healthy people “will risk endangering their health for the sake of mental improvement remains to be seen” (Ackerman, 59). And, in an extreme case, will society “be willing to relax the safety standards for an enhancement drug that produces a very substantial effect, catapulting the user from, say, average intelligence to brilliance in one dose” (Ackerman, 59)? All of these issues will make the development of regulations very difficult.
Enhancement of cognition in normal people has become and “is now a fact of life, and the only uncertainties concern the speed with which new and more appealing enhancement methods [with less adverse side effects] will become available and attract more users” (Farah, 24). Overall, I feel the public fear or feeling that brain enhancement and manipulation is wrong and dangerous will pass. It is a possibility that our innate fear of the new and novel leads to the questions and concerns about psychopharmacology. As Donald W. Pfaff writes in A Brain Built for Fair Play, this fear may then manifest in and serve as a basis “for the human instinct for fair play” (41). Are we trying to protect the vulnerable because “at some time in our lives, we will all be vulnerable” (Ackerman, xii)? Are we simply afraid and do not want others to propel ahead of us in academia, for instance? This fear may cause us to apply the Golden Rule and then use the inequity reason as a basis for rejecting enhancement.
There were many novel techniques that were historically looked down upon but are currently widespread. Paradigms change as do standards in society; as Mark Waymack states in Philosophy of Medicine, “history is replete with medical innovations that were reviled, contested, and that some medical authorities tried to prevent, but which we now gladly accept as valuable, appropriate, and perhaps even at the core of good medical practice” (91). Gregory Pence, in Re-Creating Medicine, points out that as late as the mid-19th century “it was considered unprofessional (and unethical) for a physician to visually examine a woman’s genitalia” (91). For many years, “women in childbirth were not offered painkillers” (91). These practices were thought as morally wrong but were adapted as time progressed. A “similar uneasiness” was even “evident in the early discussions of the human genome project;” it is a “control issue and a fear that at some point scientists are going to unalterably change the fundamental sense of what it means to be human or to control one’s world” (Ackerman, 114). Most people accept the “augmentation of our facilities on the outside of the skull, comfortably wearing glasses or contact lenses or even cochlear implants, yet feel uneasy at the prospect of someone tinkering with the equipment inside” (Ackerman, 113). I believe this barrier partially has to do with “a shortfall in the public misunderstanding of science” so educating the public to allow them to perform more realistic risk-benefit analyses is critical. With education and time, I believe society will adapt to the use of psychopharmacology for enhancement as it has to the plethora of other treatments or activities.
As I hope to have shown with the example at the beginning of the paper, the decision about whether using “enhancement drugs” is ethical “does not require long thought or debate when the life of someone we care about might hang in the balance; an ethics of enhancement would play no part in this choice” (Ackerman, 75). Not all enhancement is bad and if a person wants enhancement, it does not have to be bad (Caplan, 285). Instead of “looking inward to our own nature…to see what is or is not permissible,” we need to “look outward to the world that we create, to the institutions that shape our societies, and to the relationships, especially the most intimate and enduring relationships in our lives—those with our parents, our partners, and our children—those relationships that are so central to our flourishing—and to ask, ‘What will be the likely impact of any particular enhancement technology on the possibility of fulfilling those relationships” (Ackerman, 76).
I have come to a conclusion that there would be no detrimental consequences and, consequently, psychopharmacological enhancement should not be prohibited or restricted upon. This does not imply, however, that individuals should not think for themselves and perform risk-benefit analyses about whether to take specific enhancement medication or not. It is essential that consumers do not take “unknown risks for scientifically but well-advertised benefits” (Greely, 90). We, as a society, must also not become over-reliant on drugs to make us better or to fix our problems (which, consequently, may eliminate the intimate doctor-patient relationship.
I believe the practice of cosmetic neurology is inevitable. Many people are “predicting that the 21st century will be the century of neuroscience. Humanity’s ability to alter its own brain function might well shape history as powerfully as the development of metallurgy in the Iron Age, mechanization in the Industrial Revolution, or genetics in the second half of the twentieth century” (Farah et al., 289). There is always the possibility that good science aimed at the treatment of neurological disease may be applied for enhancement purposes. We must never cease to examine the “benefits and dangers of neuroscience-based technology, or ‘neurotechnology,’ and consideration of whether, when, and how society might intervene to limit its uses” (Farah et al., 289). Until we have “disentangled the a priori from the empirical claims, and evaluated the empirical claims more thoroughly, we are at risk of making wrong choices” (Farah et al., 297). Thinking about and considering such neuroethical problems “may help us maximize the benefits and minimize the harms of the revolution in brain science” (Greely, 94). When we deal with brain science, we are “dealing with the organ that makes us unique individuals, that gives us our personality, memories, emotions, dreams, creative abilities, and at times our sinister selves” (Ackerman, xii). We, as a society, must remain careful and attentive since the brain is, after all, “the seat of what we consider our humanity” (Ackerman, ix).
Psychopharmacological enhancement will go on to challenge current philosophical beliefs as it already has. As Farah and Wolpe state, “brain-based enhancement [is] forcing us to confront the fact that we are physical systems. If specific abilities, personality, traits, and dispositions are manifest in characteristic patterns of brain activation and can be manipulated by specific neurochemical interventions, then they must be a part of the physical world” (54). This realization and idea, however, “does not mesh easily” with our intuitions about personhood and the traditional ideas regarding the soul or the “nonmaterial component of the human mind” (Farah & Wolpe, 54). If the self or soul can be changed physically and chemically, is it truly immaterial?
Regardless of the answer to that question, we should not be afraid to challenge current beliefs and progress. As Pence states, “we are on the age of exciting new frontiers in medicine” (290). “Medical advancement can reshape what it means to be human: better athletes through enhancement medicine, brighter and funnier children through cloning, and three careers instead of one-plus-retirement as longevity increases” (180). Instead of being fearful, we need to embrace this “exploding knowledge” that “is giving us new opportunities, if not for ourselves, then for the next generation” (180). Hippocrates once said that “life is short, science is long; opportunity is elusive, experiment is dangerous, judgment is difficult.” Psychopharmacological enhancement has a possibility to increase opportunity and make our judgment sharper, making science easier and our lives, longer, better, and more pleasant.
1. Defining Right and Wrong in Brain Science, essential Readings in Neuroethics (edited by Walter Glannon, Ph.D.)
- Visions for a New Field of “Neuroethics” by William Safire [from Neuroethics: Mapping the Field (Dana Press, 2002):3-9]
- Emerging Ethical Issues in Neuroscience by Martha J. Farah [from Nature Neuroscience 5 (2002):1123-1129]
- Monitoring and Manipulating Brain Function: New Neuroscience Technologies and Their Ethical Implications by Martha J. Farah and Paul Root Wolpe [from Hastings Center Report 34, no. 3 (May-June 2004):35-45].
- Neuroscience and Neuroethics by Donald Kennedy [from Science 306, October 15, 2004].
- Ethical Issues in Taking Neuroscience Research from Bench to Bedside by Alan I. Leshner [from Cerebrum 6 (2004):66-73].
- Better Memories? The Promise and Perils of Pharmacological Interventions by President’s Council on Bioethics [http://www.bioethics.gov/background/better_memories.html]
- Psychopharmacology and Memory by Walter Glannon [from Journal of Medical Ethics 32 (2006):74-78]
- Shall We Enhance? A Debate by Arthur L. Caplan and Paul R. McHugh [from Cerebrum 6 (2004):13-29]
- Neurocognitive Enhancement: What Can We Do and What Should We Do? by Martha J. Farah, et al. [from Nature Reviews Neuroscience 6 (2004):421-425]
- The Promise and Predicament of Cosmetic Neurology by Anjan Chatterjee [from Journal of Medical Ethics 32 (2006):110-113]
2. Hard Science, Hard Choices: Facts, Ethics, and Policies Guiding Brain Science Today by Sandra J. Ackerman [Dana Press, 2006]
3. Philosophy of Medicine by Mark Waymack
4. The Dana Foundation’s Cerebrum (2007)
- Transforming Drug Development Through Brain Imagining by Paul M. Matthews
- A Brain Built for Fair Play by Donald W. Pfaff
- Knowing Sin: Making Sure Good Science Doesn’t Go Bad By Henry T. Greely, J.D.
- Re-Creating Medicine by Gregory E. Pence
5. Nephrarious Goings On: Kidney Sales and Moral Arguments by Janet Radcliffe Richards [from Journal of Medicine and Philosophy 21 (1996)532-544]
6. Hippocrates, Hippocratic writings. Edited with an introduction by G.E.R. Lloyd. Harmondsworth (Penguin), 1978, 206.
7. The Reviewed Warning for Antidepressants and Suicidality: Unveiling the Black Box of Statistical Analysis. Andrew C. Leon. Am J Psychiatry 164:12 December 2007.
Gennadiy Katsevman (’10) is a Philosophy major at Loyola University Chicago.
Art courtesy of adnrey