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."
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?
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. ▪