Navigating the Ethics of Agents for Pharmacological Cognitive Enhancement

Pharmacologic advancements for the treatment of neurologic disorders such as attention-deficit/hyperactivity disorder (ADHD), schizophrenia, and Alzheimer disease have provided patients with the much-needed opportunity to function and succeed in their studies, careers and, ultimately, their lives. However, with the increased availability of such ‘smart drugs’ comes the potential for misuse by healthy individuals for the purpose of enhancing cognitive function. This has created much neuroethical debate, primarily because of increasing use of agents for pharmacologic cognitive enhancement (PCE) despite the absence of adequate studies on the efficacy and risks posed to healthy brains.¹

The most commonly used drugs for PCE are methylphenidate (prescribed for ADHD) and modafinil (prescribed for wakefulness). Studies have shown that such drugs increase cognitive function and ability to reflect, but only when used at the correct dosage.^2,3 Sharon Morein-Zamir, PhD, of the University of Cambridge, United Kingdom, has written several academic papers on smart drugs. “As far as the validity of neuroethical concerns, there is no simple answer, as it depends on the drug and on the person — even in healthy individuals,” she told Neurology Advisor in an interview. She believes there are many factors to consider, such as individual susceptibility to side effects, age, current level of sleep deprivation, and stress levels. “Most smart drugs have quite modest effect sizes for many people, and their influence can change between one administration and the next,” she added.

Even if we proceed with the unsupported assumption that the efficacy of agents for PCE has been established, it is still necessary to consider the harm that it could cause to healthy individuals.⁴ “The most immediate and pressing ethical issues are related to safety, especially with access to such drugs over the internet,” Dr Morein-Zamir said. “I used to think common sense and considerations of being monitored by a healthcare professional would encourage people to treat the internet with suspicion as a valid source of any drug, but I’m not so sure anymore.”

According to researcher Nick Davis, PhD, neuroethical concerns come into play most strongly when the drugs are used covertly to gain an advantage over others.⁵ Neuroscientist Anjan Chatterjee, MD, FAAN, of the University of Pennsylvania in Philadelphia, agrees that the key issues in the neuroethical debate are “those of authenticity and a worship of a form of productivity and material progress that drives the use of these medications.” Dr Morein-Zamir added, “There are plenty of potentially positive implications for some people, especially patients or those [with] impairment in their lives such as a disorder that influences their cognition directly or indirectly. There is no black or white.” Indeed, there are many questions to consider in this debate and none of them have simple answers.⁶

Character vs Performance

If struggle builds character, does the habitual use of smart drugs erode it? “[Drugs for] PCE are obtained easily on most college campuses without a prescription,” Dr Chatterjee said. If a drug that is readily available can help to reduce the amount of work required to succeed, is it considered cheating to use the drug in a competitive environment? The answer to this remains speculative at best.

Life Is Not Fair

If only a select few have access to performance enhancements, then they could also be perceived as cheating. On the other hand, not all brains are equal and success naturally comes more easily to some than it does to others. It is not considered unethical to use natural aptitudes to succeed. Is it then unethical to purchase such aptitude? Dr Chatterjee maintained, “The data suggest that students in competitive schools who themselves are not the very best students are more likely to take these drugs.” For these students, who do not have a natural cognitive aptitude, PCE agents provide a means to compete academically at the same level as those who do have a natural aptitude, arguably helping to level the playing field.

Peer Pressure for Productivity

Theoretically, peer pressure and coercion to take PCE agents could increase with the growing use and availability of smart drugs. Dr Chatterjee believes there is a deeper issue that underpins these behaviors, however. “We deify specific forms of competitiveness and productivity. Widespread use of PCE [agents] is a symptom of that deification,” he said.

All Work and No Play

Another concern is that the use of smart drugs to succeed academically necessitates their continued use to keep succeeding after school. The focus on enhanced cognitive function could sideline equally important aspects of life such as health and relationships. “One would need to consider different contexts (such as work, study, play) and the trade-offs involved in taking or not taking such drugs. For a small group of people, these medications are extremely useful. However, the medications are now used much more widely,” Dr Chatterjee said.

Dr Morein-Zamir had similar concerns, stating, “So far, concerns about lifestyle choices do not seem to have been borne out by many. [Additionally], real life starts getting in the way — is someone enhancing just their cognition, their mood, or something else? Are they developing a psychological dependency or bowing to peer-pressure? Are they using the drugs in a controlled manner while being monitored?”

Are Smart Drugs Ethical?

Both Dr Morein-Zamir and Dr Chatterjee feel there are currently no straightforward answers to the neuroethical dilemmas posed by smart drugs. “Before much can be said with confidence about the short- and long-term effects of PCE agent use in healthy people, a lot of difficult, time-consuming, unrewarding systematic work [that] costs a lot of money is needed to map out the different drugs and different populations, taking it outside the realm of the vast placebo effects and shoddy methodologies with sampling bias,” Dr Morein-Zamir said. She believes that more evidence is needed before decisions are made, concluding, “I’m cautious on the one hand, yet hesitant to ‘close the door’ on what could have the potential to actually help lots of people in different situations.” Dr Chatterjee is similarly reserved and believes, “Better brains are better. However, what constitutes a better brain is far from obvious.”

References

1. d’Angelo L-SC, Savulich G, Sahakian BJ. Lifestyle use of drugs by healthy people for enhancing cognition, creativity, motivation and pleasure. Br J Pharmacol. 2017;174:3257-3267.
2. Urban KR, Gao W-J. Performance enhancement at the cost of potential brain plasticity: neural ramifications of nootropic drugs in the healthy developing brain. Front Syst Neurosci. 2014;8:38.
3. Franke AG, Gränsmark P, Agricola A, et al. Methylphenidate, modafinil, and caffeine for cognitive enhancement in chess: a double-blind, randomised controlled trial. Eur Neuropsychopharmacol. 2017;27(3):248-260.
4. Sahakian BJ, Morein-Zamir S. Pharmacological cognitive enhancement: treatment of neuropsychiatric disorders and lifestyle use by healthy people. Lancet Psychiatry. 2015;2:357-362.
5. Davis NJ. A taxonomy of harms inherent in cognitive enhancement. Front Hum Neurosci. 2017;11:63.
6. Maslen H, Faulmüller N, Savulescu J. Pharmacological cognitive enhancement—how neuroscientific research could advance ethical debate. Front Syst Neurosci. 2014;8:107.