ARTICLE IN BRIEF
✓ A forum of experts discussed the ethical issues that emerge when pharmacological therapies are used for purposes other than treating illness.
WASHINGTON—Increasingly, people who have no diagnosed neurological or neuropsychiatric conditions are using so-called “smart drugs” — such as medications for attention deficit hyperactivity disorder (ADHD), for example — to enhance their cognitive performance. But just how smart is it for normal people to use these drugs? Since all drugs have side effects, are people who have no diagnosed disorders running risks? Is it fair for those who can pay for these drugs to use them, when the less privileged cannot?
These were among the questions for discussion among invited panelists in May at a forum here on the ethics of neuroenhancement. The forum was sponsored by the Neuroethics Society and hosted by the private, philanthropic Dana Foundation.
“Enhancement straddles health; it has applications to well people, the military, and students who study for exams,” said Steven E. Hyman, MD, provost of Harvard University and professor of neurobiology at Harvard Medical School. “There's a very worried tone to the literature and the writing” about cognitive enhancement, noted Dr. Hyman, a former director of the National Institute of Mental Health.
“We're very comfortable with SAT tutoring, special coaches, and piano lessons,” he said. “But when we shift from behavioral interventions to pharmacology, we get uncomfortable,” because altering the brain pharmacologically raises neuroethical questions.
THE GRAY ZONE
There is “clearly no bright line between the impaired, those not-impaired, and the ill,” he said, so treating illness and enhancing cognitive performance can fall into a gray zone. Given that physicians are free to prescribe drugs off-label, they need to exercise care when it comes to patients who want drugs for cognitive enhancement, Dr. Hyman emphasized.
“Physicians have to be responsive to their patients, but they shouldn't be like waiters at a café,” he said. He noted that concerns about issues such as mental enhancement in normal people are what spurred formation of the interdisciplinary Neuroethics Society in 2006 (See “More About the Neuroethics Society”).
COGNITIVE ENHANCEMENT: THE DILEMMAS
In fact, neuroenhancement is already in full swing, according to panelists at the forum. ADHD drugs such as amphetamine (Adderall) and methylphenidate (Ritalin) have a street value among college students because they increase dopamine in the prefrontal cortex, said Martha Farah, PhD, Walter H. Annenberg Professor of Natural Sciences and director of the Center for Cognitive Neuroscience at the University of Pennsylvania. One study found that 7 percent of 10,000 college students used prescription drugs for cognitive enhancement. She said that number is as high as 25 percent on some extremely competitive college campuses.
“What does this do to the way you think?” asked Dr. Farah. “Is it deleterious to some people? The individual-differences variable is an important one.
“Our society needs to wake up and take this growing phenomenon seriously,” Dr. Farah said. “It doesn't seem to have registered on the public health radar screen.”
Dr. Farah compared cognitive enhancement to plastic surgery, noting that that field has broadened from correction of facial abnormalities or disfigurement through injury to cosmetic enhancement. She also cited infertility treatments and strategies to improve sports performance as examples of fields that have expanded beyond disease.
Barbara Sahakian, FMedSci, professor of clinical neuropsychology at the Department of Psychiatry at the University of Cambridge School of Clinical Medicine in the UK, agreed. “At the University of Cambridge, she said, students take methylphenidate to help them achieve mentally and claim that it works.
Dr. Sahakian is studying modafinil (Provigil), which is approved for excessive daytime sleepiness associated with narcolepsy. This drug, too, has a street value. “Some people use it for jetlag,” she said. “It may enhance norepinephrine and acetylcholine. This drug enhances executive function and memory with minimal side effects.” She noted that there are now about 40 neuroenhancing drugs in development.
ETHICAL CONSENT IN THE MILITARY
Cognitive-enhancement drugs are nothing new for the military and raise issues of ethical consent, said Turhan Canli, PhD, associate professor of biopsychology at the State University of New York-Stony Brook. “The military has been using amphetamines to keep people going,” he said. “This has a long history going back to World War II.”
“Can we prevent cognitive deficits from sleep loss? The military is interested in this,” he said. “The issue becomes exacerbated when you're talking about soldiers as subjects.”
The bottom line, said Dr. Canli, is that those in the military may not have a choice to consent to the use of cognitive-enhancing drugs, and may be forced to use them to offset sleep loss. “We have an all-volunteer army; we're putting them at a high level of risk,” he noted. The implicit message soldiers may receive, said Dr. Canli, is: “Take your pills or you may be shot (by the enemy) or court martialed.”
“I'm less concerned about drugs than I am about dietary supplements,” said Henry T. Greely, JD, Deane F. and Kate Edelman Johnson Professor of Law and professor of ethics at Stanford University. “If you go to a health food store, you'll see claims for enhancement. I think this raises issues of safety and consumer fraud.” He noted that dietary supplements, a $50 billion industry, are poorly regulated.
Greely posed these questions for consideration: If cognitive and memory enhancers are available only to the rich and the rich get richer and smarter, is that fair? Should students with no diagnosed condition be tested for the use of cognitive enhancers? Should cognitive-enhancing drugs be banned except for those with a diagnosed condition? How can such drugs be used to maximize their benefits and minimize their harms? “Our society doesn't regulate this at all yet,” he said.
Asked by Neurology Today if the Federal Trade Commission, which regulates truth in advertising, is adequately policing performance-enhancing ads for dietary supplements, Greely said the agency is ineffective. “Perhaps we need to think about ways other than regulation to govern advertising,” he said. “Our society isn't very good at regulating advertising. We can pass laws regulating a lot of things that don't affect what's happening in the real world.”
One questioner asked whether cognitive-enhancing drugs might be used for impulse control, citing a disturbing personal incident with road rage. “Impulse control is a problem in many neuropsychiatric diseases,” said Dr. Sahakian. “There's a lot of work now going on social decision-making,” added Dr. Canli. “With imaging we can identify some of the circuitry involved.” But, he cautioned, “As we learn more there's a tendency to medicalize these behaviors.”
And one questioner cited the “woebegone” effect — the desire in every human being to be above average; won't cognitive enhancement in normal people just drive the bell-shaped curve of cognitive performance higher? Even if the performance curve is ratcheted up and shifted higher, said panelists, there will still be disparities, since human beings are all different and have different abilities.
MORE ABOUT THE NEUROETHICS SOCIETY
The Neuroethics Society was established after a small meeting in Asilomar, CA, in May 2006, to “promote the development and responsible application of neuroscience through better understanding of its capabilities and its consequences,” according to its mission statement.
“About a year ago we decided that the world did need another professional society,” said Harvard Provost Steven Hyman, MD, the society's first president. The interdisciplinary society has a 14-member governing board, including a president and an executive committee of five.
The first two meetings of the society will be held as satellite meetings of the Cognitive Neuroscience Society in mid-April 2008, in San Francisco, and mid-April 2009 in New York City. The society plans to host events at other meetings in 2007. For further information, visit www.neuroethicssociety.org.