Where Is Line Between Therapy, Enhancement?

Medications intended to treat mental illnesses are increasingly used by healthy people to remember a little more, think a little faster, pay a little more attention, feel a little more confident, and be a little smarter. This practice is spurring debate among bioethicists, politicians, neuropsychological scientists, and public-health researchers.

Is it wrong for healthy people to use psychoactive medications to enhance their mental abilities? Should they be discouraged or prohibited from doing so? Should physicians and researchers help healthy people become smarter with medications? Where do psychiatrists stand on the debate?

Richard Rosenthal, M.D., chair of psychiatry at St. Luke's-Roosevelt Hospital Center, a New York hospital affiliated with Columbia University, posed these questions in his keynote speech at the American Academy of Addiction Psychiatry annual meeting in Boca Raton, Fla., on December 5, 2008.

The antidementia drug donepezil has been shown to improve pilots' reaction and concentration in clinical trials. College students without attention-deficit/hyper-activity disorder are taking stimulants to help them study longer and improve memory. Silicon Valley overachievers often take mondafinil so that they can work longer hours and stay sharp. These are only a few examples of how healthy people are increasingly using prescription drugs for non-illness gains.

An informal survey by Nature in January 2008 found that 20 percent of its 1,400 readers, who are predominantly scientists, admitted to taking mind-enhancement medications such as methylphenidate, modafinil, or beta blockers for nonmedical reasons.

This type of use usually does not constitute substance abuse, although some of these drugs, such as stimulants, have abuse potential. Many of these drugs have fairly low risk of adverse effects.

The use of medical technology for purposes beyond treating illnesses is largely opposed by the President's Council on Bioethics, an advisory group set up in 2001 to advise the president on bioethical issues. All council members have been directly appointed by President Bush, and fewer than half of the past and current members are physicians.

In an October 2003 report “Beyond Therapy: Biotechnology and the Pursuit of Happiness,” the council suggested that the use of biotechnology for enhancement, rather than therapy for illnesses, is unethical and conflicts with the “American ideals.” They are also worried that the pursuit of “superior performance ... will be achieved only at the price of our integrity and dignity.”

Opponents Fear Dehumanization

Rosenthal argued, however, that the moral aspects of cognitive and other enhancements for healthy people are far from black and white. The line between enhancement and therapy is not always clear cut, because the differences of health, subclinical disease, and disease are not absolutely distinct.

Rosenthal pointed out that efforts to improve human limits have always been a part of the human condition. Nonmedical means of cognitive enhancement are generally accepted as perfectly ethical. “Why is psychotherapy or tutoring acceptable, but not medications?” he asked.

Taking prescription drugs to enhance mental abilities still makes many people within and outside of medicine uneasy, yet many medical interventions intended to reverse the effects of aging and improving the quality of life, such as drugs for treating erectile dysfunction and cosmetic procedures, have been accepted by society. Rosenthal questioned whether there are any real differences between these types of enhancements. For example, caffeine is a legal substance that enhances attention and cognitive function. In other words, drinking coffee may not be fundamentally different from taking modafinil to do better work.

At the center of the argument against artificial enhancements to natural health is a “tension between the competitive reality and social contract,” Rosenthal said. Such enhancements may give people who can afford them an “unfair advantage” that may be inconsistent with the concept of fairness and equality. On the other hand, inequality permeates all aspects of society. People are not born with the same abilities and deficits. Rosenthal noted that, in reality, difference in socioeconomic status already causes inequalities in, for example, nutrition and education, which lead to inequality in mental development.

Another argument against enhancements is the possibility of direct or indirect coercion with the widening availability and use of “cosmetic psychopharmacology.” For example, should pilots be required to take cholinesterase inhibitors to fly safer? Will parents feel compelled to give medications to their children in order to “keep up” with other children's school performance?

Supporters Consider It Progress

There are voices in favor of not only permitting but also researching and developing these mind-enhancing technologies. A group of prominent researchers expressed their support for “responsible use of cognitive-enhancing drugs for the healthy” in a commentary published in Nature online on December 7, 2008.

These authors believe that the use of cognitive-enhancing drugs not only should be allowed but should be actively developed and made available to the public through research of their benefits and risks. “The drugs ... along with brain stimulation and prosthetic brain chips, should be viewed in the same general category as education, good health habits, and information technology,” they wrote. The authors acknowledged that some of these drugs may be abused, but pointed out that regulating rather than prohibiting substances with abuse potential is nothing new.

Among the authors of the commentary were Barbara Sahakian, a professor of clinical neuropsychology at the University of Cambridge School of Clinical Medicine in the United Kingdom; Ronald Kessler, Ph.D., a professor of health care policy at Harvard Medical School; Michael Gazzaniga, Ph.D., a professor of psychology and director of the SAGE Center for the Study of Mind at the University of California, Santa Barbara, and a member on the President's Council on Bioethics; and Martha Farah, Ph.D., a Walter H. Annenberg Professor of Natural Sciences and director of the Center for Cognitive Neuroscience at the University of Pennsylvania.

Weighing the relative risks and benefits of a new drug or technology is a paradigm central to medical research, and this paradigm can be used to consider cognitive and other enhancements for healthy people as well, Rosenthal suggested. The difficulty, however, is that enhancements have barely been studied in clinical research, leaving physicians and psychiatrists with little or no evidence to make a judgment on particular questions, he said.

Reality is not waiting for psychiatry, bioethicists, and politicians to sort out the ethical complexities and come to a consensus on public policies, however. “Society hasn't laid out the rules, it's a big mess,” said Rosenthal. People are doing what they feel compelled to do. The number of people using these mind-enhancing drugs for nonmedical purposes will continue to grow, both Rosenthal and the Nature commentators believe. The trend seems inevitable.

“What enhancements have we been able to successfully avoid?” Rosenthal's question brought a room of laughter.

Perhaps the real question is how science and medicine will steer policies toward more rational and equitable use of enhancements for social good rather than banning them. ▪