The idea that we can get better grades at school and advance our careers by taking drugs that improve concentration and other brain functions is at once controversial and tempting. Is this cheating, or is it in the same realm as drinking coffee to increase alertness? Bioethicists, medical professionals, and the general public are divided on this question.
What’s not contested is that teenagers and adults are using prescription medications such as Ritalin for nonmedical purposes in an attempt to enhance normal cognitive functioning. As an article in yesterday’s New York Times put it, “these drugs are used not to get high, but hired.” People are getting the drugs from doctors, or from patients (such as classmates) with prescriptions for neurological conditions who are willing to sell or share their pills.
Against this Wild West backdrop, the Presidential Commission for the Study of Bioethical Issues (PCSBI) has taken a significant step by issuing recommendations on the ethical use of medications and other means of “neural modification,” the term PCSBI uses to include drugs and interventions such as deep brain stimulation, which might either treat neurological disorders or augment normal brain function. The recommendations are part of its final report, Gray Matters: Topics at the Intersection of Neuroscience, Ethics and Society.
“No comprehensive or agreed-upon guidance or best-practices document is available to advise stakeholders (including clinicians, employers, parents, educators, and patients, among others) about potential benefits and risks inherent in using a neural modification intervention,” the PSCBI’s report says. “Educators, parents, clinicians, and employers in highly competitive fields would benefit from having expert, evidence-based advice when faced with student or employee use of neural modification interventions.”
The report cites recent data that speak to this need. One in five respondents to a poll by the journal Nature said that they had used Ritalin, Provigil (a prescription drug for narcolepsy), or beta-blockers for nonmedical purposes, such as increasing focus or memory. Among college students ages 18 to 22, 6.2 percent said that they had used Adderall (a drug for attention deficit–hyperactivity disorder and narcolepsy) to improve concentration, focus, and alertness, according to the most recent National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration.
Children are also using such drugs for cognitive enhancement, and this use is increasing, the PCSBI says. It cites a survey of 12th graders in the United States in which 4 percent said that they had used Adderall and 2 percent said that they had used Ritalin in the previous year without a doctor’s prescription.
Those who firmly believe that college students without ADHD who take Ritalin before finals are cheaters or that people in hard-driving careers who use drugs to sustain a seemingly inhuman output of work are frauds (or victims of coercion in a hypercompetitive job market) are likely to be disappointed by the commission’s report. It is guardedly optimistic about the prospects for neural modification for enhancement purposes, stating that “contemplating novel methods of improving such functions as learning and memory in school or performance in competitive professions is truly exciting.” The commission does not assume that cognitive enhancers will necessarily promote injustice (by benefiting mainly those who are able to afford them) or help level the playing field (by enabling people with below average but still normal memory and other brain functions to perform better). But it concludes that it’s worth finding out.
The commission says that we need to know more about the risks and benefits. While the risks of some drugs used as cognitive enhancers are known – for example, Ritalin and Adderall are on the list of federal controlled substances because of their potential for abuse and dependency—the risks and benefits of these and other interventions are largely unknown. Getting this basic information is a prerequisite for deliberating on which cognitive enhancers might be morally acceptable, for whom, and under what circumstances.
PCSBI calls for scientists, funders, and bioethicists to consider each cognitive enhancer on a case-by-case basis by taking into account key questions: What is it used for? By whom? How effective is it for this purpose? Who will benefit the most? What are its risks?
Here are its recommendations:
More research. “Funders should support research on the prevalence, benefits, and risks of novel neural modifiers to guide the ethical use of interventions to augment or enhance neural function.”
- Equitable access. “Policymakers and other stakeholders should ensure that access to beneficial, safe, effective, and morally acceptable novel neural modifiers to augment or enhance neural function is equitable so as not to compound or exacerbate social and economic inequities.” One way to do this is to get more information on who benefits most from which enhancements. For example, PCSBI says that limited evidence indicates that some cognitive enhancement technologies might be most beneficial to those “most in need.” (It doesn’t elaborate on what it means by “need.”) “If this is demonstrated to be the case, these technologies might reduce gaps in cognitive performance that can have substantial implications for an individual’s social and economic position.”
- Professional guidance. “Professional organizations and other expert groups should develop guidance for clinicians, employers, parents, educators, and patients about the use of neural modifiers and their potential risks and benefits. Medical professional organizations should develop guidelines to assist clinicians in responding to requests for prescriptions to expand or augment neural function.”
PCSBI argues for one clear restriction, and it is hard to imagine any disagreement about it: “Clinicians should not prescribe medications that have uncertain or unproven benefits and risks to augment neural function in children and adolescents who do not have neural disorders.”
UPDATE: The New York Times invited several people, including Hastings Center scholar Erik Parens, to write commentaries on the use of Adderall as a cognitive enhancer in the workplace. Their range of views appears in Room for Debate.
Susan Gilbert is the public affairs and communications manager of The Hastings Center and editor of Bioethics Forum.