Expectations regarding Cognitive Enhancement Create Substantial Challenges

Author(s): E. Racine and C. Forlini

Source: Journal of Medical Ethics , Aug., 2009, Vol. 35, No. 8 (Aug., 2009), pp. 469-470
Published by: BMJ

Stable URL: https://www.jstor.org/stable/27720379

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1 Neuroethics Research Unit,
Institut de recherches cliniques
de Montr?al, Department of
Medicine and Department of
Social and Preventive Medicine,
Universit? de Montr?al, and
Department of Neurology and
Neurosurgery & Biom?dical
Ethics Unit, McGill University,
Montr?al, Canada;2 Neuroethics
Research Unit, Institut de
recherches cliniques de
Montr?al, Montr?al, Canada
Correspondence to:
Eric Racine, Neuroethics
Research Unit, IRCM, 110
avenue des Pins Ouest,
Montr?al QC H2W IR7, Canada;
eric.racine@ircm.qc.ca
Received 25 March 2009
Accepted 20 April 2009
J Med Ethics 2009;35:469-470. doi:10.1136/jme.2009.030460 469
Expectations regarding cognitive enhancement
create substantial challenges
E Racine,1 C Forlini2
ABSTRACT
A recent discussion on cognitive enhancers has caused
some controversy in the ethics and neuroscience fields by
coming out in favour of making neuropharmaceuticals
with enhancing properties available for general con
sumption. We highlight in this brief commentary why
concerns regarding efficacy and safety, demands on
resources, and public health are substantive enough to
warrant serious reconsideration before pharmaceutical
performance enhancement can be widely supported.
In a recent paper published in Nature, Greely and
colleagues come out in favour of making cognitive
enhancers available for general consumption.1 They
acknowledge a number of substantive concerns such
as safety, freedom from coercion, fairness, research
based evidence, engagement of professional societies,
better public understanding and limited legislative
action. Nonetheless, the authors advocate for the
responsible use of cognitive enhancers by the
healthy. We would like to suggest that the ethical
and practical challenges involved in the wide use of
drugs for performance enhancement should not be
underestimated. We highlight in this brief commen
tary why concerns regarding efficacy and safety,
demands on resources, and public health are
substantive enough to warrant serious reconsidera
tion before pharmaceutical performance enhance
ment can be widely supported.
SAFETY AND EFFICACY
The authors acknowledge that "it is too early to
know whether any of these new drugs will be
proven safe and effective" but they also write that
"many of the medications used to treat psychiatric
and neurological conditions also improve perfor
mance in the healthy".1 It is important to stress that
sizeable gaps exist in our current understanding of
the effects, both positive and negative, of neuro
pharmaceuticals on healthy individuals. Studies
published so far on the enhancement effects of
stimulants are a crucial start.2-6 However, they are no
substitute for large-scale randomised clinical trials.
The published studies are also primarily based on
tasks that do not reflect the complexity and diversity
of activities in learning and thinking. Given these
observations, the term "cognitive enhancement77
itself (somewhat like the term "gene therapy77) is
debatable in so far as it implies efficacy that has not
been established. To avoid making promises through
scientific and ethical terminology, a more neutral
term (eg, "non-medical use of prescription drugs77)
could be used by the community of interested
stakeholders to convey the state of current evidence.
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Controversy
DEMANDS ON HEALTHCARE RESOURCES
Based upon the expected efficacy of drugs to
enhance performance, Greely and colleagues state
that "a proper societal response will involve
making enhancements available while managing
their risks77.1 Our view is that the additional
demand for healthcare services needed to mitigate
the overall impact of widespread non-medically
indicated uses of prescription drugs may place
further pressure on current professional and
healthcare resources. At this point, we should keep
in mind that equitable distribution of resources for
essential healthcare is already a challenge. As the
authors rightly suggest, a research programme, the
creation of public policies and dissemination of
sound information would need to be supported but
the health policy and public health impact of drugs
used for performance enhancement remains poorly
understood and hard to predict. Further, the
health-service demands to which a favourable
approach might give rise could undermine health
care systems that are based on the values of
individual rights and the public good. These
systems need to prioritise demands for healthcare
fairly and ensure their legitimacy in addition to
respecting individual preferences.
PUBLIC HEALTH AND INTERNATIONAL DEBATE
Greely and colleagues affirm that performance
enhancing drugs "should be viewed in the same
general category as education, good health habits,
and information technology,77 in as much as they
are ways that "our uniquely innovative species
tries to improve itself7.1 The comparison between
performance enhancers and other forms of cultural
and technological innovation merits careful scru
tiny. Even if efficacy in healthy individuals would
be proven, some might be hesitant to regard
neuropharmaceuticals as acceptable interventions
to respond to social demands for heightened
performance and productivity. Already, public
health perspectives grounded in concerns such as
dependency, abuse and health literacy are much
less enthusiastic about the non-medical use of
prescription drugs.7 8 Protecting vulnerable popula
tions against the imposition of performance
enhancing drugs may be an important challenge.
Further, we should bear in mind that increased
non-medical use of neuropharmaceuticals would
occur in an internationally competitive socioeco
nomic context and bring about related social and
healthcare consequences. The use of performance
enhancing drugs is unlikely to eradicate existing
inequalities, which may ultimately be perpetuated
when performance enhancements are sought as
means to cope with these situations. Given the
 Controversy

broader interests and considerable implications of performance Competing interests: None declared.

enhancement with prescription drugs, public information and
debate beyond academia is ethically required.
Before accepting the widespread use of prescription drugs for
performance enhancement, we need additional evidence of
efficacy, a better understanding of the impact of these
behaviours on healthcare systems, and further international
discussion regarding the consequences on individual rights in a
world that will view performance enhancement as a means to
perpetuate existing goals, both good and bad. Until then, we are
not in a position where a balance has been struck between the
principles of non-maleficence, justice and autonomy on this
pressing social issue.
Acknowledgements: We would like to thank members of the Neuroethics Research
Unit, in particular Dr Emily Bell, Dr Bruce Maxwell, and Dr Nicole Palmour for helpful
comments on this manuscript.
Funding: Support for this publication comes from the Social Sciences and Humanities
Research Council of Canada, the Canadian Institutes of Health Research and the Fonds
de la recherche en sant? du Qu?bec.
Provenance and peer review: Not commissioned; externally peer reviewed.
REFERENCES
1. Greely H, Sahakian B, Harris J, et al. Towards responsible use of cognitive-enhancing
drugs by the healthy. Nature 2008;456:702-5.
2. Barch DM, Carter CS. Amphetamine improves cognitive function in medicated
individuals with schizophrenia and in healthy volunteers. Schizophr Res 2005;77:43-58.
3. Bray CL, Cahill KS, Oshier JT, ef al. Methylphenidate does not improve cognitive
function in healthy sleep-deprived young adults. J Investig Med 2004;52:192-201.
4. Elliott R, Sahakian BJ, Matthews K, et al. Effects of methylphenidate on spatial
working memory and planning in healthy young adults. Psychopharmacology
1997;131:196-206.
5. Farah MJ, Haimrn C, Sankoorikal G, etal. When we enhance cognition with Adderall,
do we sacrifice creativity? A preliminary study. Psychopharmacology 2009;202:541-7.
6. Mehta MA, Owen AM, Sahakian BJ, ef al. Methylphenidate enhances working
memory by modulating discrete frontal and parietal lobe regions in the human brain.
J Neurosci 2000;20:RC65.
7. Dupont RL, Coleman JJ, Bucher RH, et al. Characteristics and motives of college
students who engage in nonmedical use of methylphenidate. Am J Addict
2008;17:167-71.
8. Rabiner DL, Anastopoulos AD, Costello EJ, etal. Motives and perceived consequences
of nonmedical ADHD medication use by college students: are students treating
themselves for attention problems? J Atten Disord 2008 Jul 29 [epub ahead of print].

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470 J Med Ethics 2009;35:469-470. doi:10.1136/jme.2009.030460

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