The Physical, Social, and Societal Consequences of “Smart” Drugs

By Sunidhi Ramesh

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris in Summer 2016.

Sunidhi Ramesh, an Atlanta native, is entering her third year at Emory University where she is double majoring in Sociology and Neuroscience and Behavioral Biology.  After experiencing an educational environment in high school that was so competitive that it practically forced students into taking study drugs, cheating, and cutting corners, she founded “The Prism Project,” an initiative that revolves around anonymous stories that highlight the problems that exist within the American education system. She plans to pursue a career in medicine and has served on College Council’s Admissions and Scholarships committee, is presently active on Emory’s Committee of Academic Integrity, and is involved in the Indian Cultural Exchange organization at Emory. 

“I remember the night I first took one. A friend of mine had some extra, so he handed me one the night before a big test. This test was important; I was doing pretty badly in the class, and I knew that my performance on it would decide my final grade. I wasn’t the type to take Adderall to get ahead. But I was desperate. And I thought it was only going to be this one time.

My grades skyrocketed. Like, you don’t understand. I played football and had to take care of my mom after school; the main reason I did so badly before was that I didn’t have the energy to put into school that I wanted to. But these pills… these pills gave me that. The energy I didn’t have.”

This quote is from an anonymous submission to The Prism Project, a page that shares the stories of students who feel as if the education system in the United States does less than it should. The topic of the quote is a subject of heated debates—“smart drugs.”

“Smart drugs,” also known as “nootropics,” are “supplement[s] that [are] ingested primarily for [their] effects on the brain [such as] an increase in cognition, focus, alertness, or well being (1)” in healthy individuals. Although the vast majority of these drugs were initially produced to treat symptoms of attention deficit hyperactivity disorder (ADHD) (2), the global demand for them (primarily for use in schools and work settings) has created a massive, up-and-coming “billion dollar business of being smart (3).”

Image courtesy of Deviant Art

And while most studies and scholars disagree on the actual effects of these drugs (ranging from “none” to “modest” improvements (4)), most researchers have expressed concern regarding their ethical implications and the consequences we may face when similar, more effective compounds are developed in the future (5).

One of the primary concerns involved is “challenging what it means to be normal.” Picture this: one student begins using these drugs to focus more and perform better on exams. He succeeds. The next student, feeling disadvantaged and conflicted, begins doing the same to keep a level playing field. And, suddenly, within weeks, a cycle of frustration and competition forces these little pills to become rampant around an entire school. This is the slippery slope that surrounds cognitive enhancements—the pressure that “normal” individuals begin to feel to become “enhanced.”

And what does this say about the future of our workforce? If our students are primed to only perform well under “enhanced” conditions, will they be able to work efficiently in their future jobs without these “smart” drugs?

Furthermore, the long-term effects of these drugs are largely unknown. A study done in doctors that “deprived [them] of sleep overnight and [gave them] a dose of 200 milligrams of Modafinil or placebo” found that “the doctors taking Modafinil had cognitive improvements, including flexibility of thinking, and reduced impulsivity.” (6) These are the positive (?), known, short-term effects. But what are the consequences of taking such medication often— for months or years at a time? Because these drugs are fairly new, nobody knows. So, should we be concerned? Of course.

Consider, also, the social consequences of a “pressure to perform” and the temptation that workers and students will face “to risk their own health to gain a competitive edge.” Is that a problem of it’s own? Taking into account the trust issues, mild paranoia, and mental stress that would inevitably ensue, I’m willing to bet it is.

What is odd and disturbing about this new trend is how idealistic people seem to be about its infectious spread. “Why would this be bad?” some people seem to claim. “One day, we will all be taking this medication to become smarter and more intelligent than ever before!” The core problem not addressed in this argument is that these medications cost money—money that only a small percentage of the American (or world) population can afford to spend on cognitive enhancement methods such as this one. This then becomes a justice problem. Is it fair to produce and allow products that, realistically, can only enhance a portion of the population?

Image courtesy of Flickr user eliz.avery

Advocates and opponents of these enhancers disagree significantly as to what exactly constitutes these “smart drugs.” Can caffeine products, such as coffee, be considered brain enhancers as well? Well, coffee and its stimulating effects are natural products of the coffee bean. More importantly, it is readily available to the masses, legal for public consumption, and free from most forms of stigma. On top of the fact that coffee has been consumed since the 10th century, there is ample evidence to ensure that its consumption does not come with any unwanted, long-term side effects. And, from a neuroethics standpoint, coffee does not bring into question concerns of justice, readiness, public involvement/understanding, integrity, and governance/ regulation. Convinced? Good.

With all this in mind, I can’t help but wonder why we (including myself!) have such a large problem with expanding our own potential as human beings. When would “smart drugs” be something desirable? Can we make our doctors more alert during 15 hour surgeries? Or soldiers more active in battle? Our pilots more attentive during international flights? Would we want this any more than we would want enhancements to the general population? I would think so. But why? What does this say about our values and our society?

Frati et al. (2015) may get into answering these questions (7), claiming that “the vast abuse of [these drugs] rises from the mental association between the therapeutic use for ADHD treatment and its misuse in order to improve learning skills in healthy subjects.” Frati’s group further states that “[the medication’s] improper use is based on exceeding the marked borderline between health and disease, which appears in the eyes of abusers increasingly blurred until it disappears (7).” So, as a result, “treatment” starts becoming synonymous with “enhancement” to dissenters around the country.

In terms of getting to the roots of the questions presented here, that’s a start.

We must stay alert when it comes to any large-scale changes that challenge what it means to be “normal” and “human” in modern society. And although larger studies on these drugs still need to be conducted to even begin to tackle the dozens of issues surrounding this topic, the “smart drugs” of today need to be discussed, debated, and monitored to avoid serious, undesirable consequences in the world of tomorrow.

References 



1. Nootropic - Scientific Review on Usage, Dosage, Side Effects. (n.d.). Retrieved June 11, 2016, from https://examine.com/supplements/nootropic/



2. Larimer, M. P. (2005). Attention deficit hyperactivity disorder (ADHD) research developments. Nova Publishers.



3. Chinthapalli, H. U. K. (2015). The billion dollar business of being smart. bmj, 23.



4. Arria, A. M., Wilcox, H. C., Caldeira, K. M., Vincent, K. B., Garnier-Dykstra, L. M., & O'Grady, K. E. (2013). Dispelling the myth of “smart drugs”: Cannabis and alcohol use problems predict nonmedical use of prescription stimulants for studying. Addictive behaviors, 38(3), 1643-1650.



5. Cakic, V. (2009). Smart drugs for cognitive enhancement: ethical and pragmatic considerations in the era of cosmetic neurology. Journal of medical ethics, 35(10), 611-615.



6. Sahakian, B. (n.d.). The Ethics of Smart Drugs. Retrieved June 11, 2016, from http://www.cam.ac.uk/research/discussion/the-ethics-of-smart-drugs



7. Frati, P., Kyriakou, C., Del Rio, A., Marinelli, E., Vergallo, G. M., Zaami, S., & Busardò, F. P. (2015). Smart drugs and synthetic androgens for cognitive and physical enhancement: revolving doors of cosmetic neurology. Current neuropharmacology, 13(1), 5.





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Ramesh, Sunidhi. (2016). The Physical, Social, and Societal Consequences of “Smart” Drugs. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/07/the-physical-social-and-societal.html

Adderall as a motivational enhancer

Prescription stimulant use is on the rise at college campuses, especially at elite schools where the pressure and demands can be overwhelming. Students have a variety of methods to handle the stresses of their studies, but the consumption of prescription stimulants, such as Adderall or Ritalin, has become more popular among healthy individuals. While this trend raises multiple important ethical issues, the interesting idea that prescription stimulants may be masking authentic versions of ourselves was the topic of the most recent Neuroethics in the News discussion. Facilitated by AJOB Neuroscience editorial intern Ryan Purcell and AJOB Neuroscience Editor John Banja, the discussion centered around a recently published article by Torben Kjaersgaard entitled “Enhancing Motivation by Use of Prescription Stimulants: The Ethics of Motivation Enhancement^."1

                                                                from Smart Drug Smarts

The cognitive enhancement debate is not new; scholars have been considering the ethical dilemmas, such as equal access, safety, coercion, and cheating, of healthy individuals seeking enhancement via prescription drugs for almost a decade.^2,3 There is also a debate surrounding whether or not current stimulants are even cognitive enhancers at all, which would render the discussion irrelevant.^4,5 Kjaesrgaard doesn’t focus on any of these issues though, and instead presents the ethical dilemmas associated with motivational enhancement of drugs such as Adderall and modafinil. He argues that these stimulants are not eliciting performance enhancement, but instead performance maintenance and sometimes increased motivation for a task, and this can often be ethically problematic. While the future may hold cognitive enhancers that have the ability to increase a person’s capability to solve a task or make an individual “smarter,” current stimulants promote wakefulness, arousal, and stimulation. The invocation of these emotions is related to motivation, and Kjaersgaard argues that motivation enhancement is an important but “neglected subitem in the bioethical debate on cognitive enhancement.”¹

 

 Motivation in this article is defined as a “broad set of affective states that influence whether a person will voluntarily use their cognitive ability in the performance of a task,” which comes from a paper by IIieva and Farah.³ Very few papers have reported on the reasons for consumption of prescription stimulants by healthy individuals, but the article alludes to a recent qualitative study published by Scott Vreko⁶ to show that students who take these stimulants are typically seeking to enhance their motivation and interest during an “Adderall” day spent studying in the library. Vrecko reported four experiential “feelings” that students experience when taking Adderall including feeling up, drivenness, interestedness, and enjoyment; feelings all related to motivation. Many of the students were unable to study unless taking the drug or felt they were more effective and interested when under the influence. It is possible that these students could be self-medicating depression or ADHD, and as problematic as that may be, what if these students are just lazy? (Kjaersgaard does note that many of the students only attribute their inability to study to factors related to school, suggesting depression is not an underlying factor). Is there really anything wrong with trying to become a more productive, studious person? If a boost in motivation is needed to study for a midterm or prepare a presentation at work, is there anything ethically fraught about seeking an external stimulant? Or, is intrinsic motivation somehow more meaningful than motivation induced by prescription stimulants? The answer, according to Kjaersgaard, is sometimes. 

Lack of motivation could be part of a much larger problem connected to the meaning, structure, and purpose in a person’s life. The constant use of prescription stimulants to get through four years of college or every task at work could signal feelings of alienation, and treating these feelings with pharmaceuticals is unethical.  A student who enjoys learning and finds it self-fulfilling, but needs to take Adderall to get through one class unrelated to his major is not participating in an unethical act because the one-time use does not change the course of his life or who he is. Most importantly, this student isn’t trying to escape from reality. However, Adderall is not helping the student that is trying to get through college as a biology major because his parents want him to go to medical school. In this instance, the student is on a path of becoming his least authentic self, a complex issue that should not be controlled with prescription stimulants. Continually using stimulants to overcome a lack of willpower means that “we risk losing touch with ourselves in some sense.”¹ When we start to regard lack of motivation as a physiological problem, instead of a vice, we are losing an essential part of the human condition and we are perhaps only masking the most authentic version of ourselves. 

                                                               from DistanceAdvising

 This twist on the cognitive enhancement debate is interesting because for the first time we live in a society where the quest to become what you may consider your most authentic self is actually possible.  Serfs in the Middle Ages were not questioning whether or not serfdom was their actual calling, and classes were still starkly divided as late as the 19^th century. Some have made the claim that we should take cognitive enhancers because we have an obligation to society to be the best, smartest, most productive versions of ourselves. But, do we instead have an individual obligation to become the most authentic, true version of ourselves? Is it even possible to find your most authentic self? And, as Dr. Banja pointed out with this Monty Python sketch, what if your true self is boring and dull? In this case the use of prescription stimulants may not be holding you back in the slightest.  

While it may be true that the fate of college students does not drastically depend on prescription stimulant use, perhaps rampant Adderall consumption is a chance to have a conversation regarding the collegiate atmosphere. In college and in life, we move at a faster pace than before and ubiquitous technology means that something or someone is constantly demanding attention. This can often make life seem overwhelming and challenging, but by accepting the occasional Adderall usage, are we ignoring other fundamental problems with our social structure? Maybe prescription stimulants are a solution for the vast majority of people that are unsatisfied with their jobs, especially if income is a priority over authenticity. But, does society suffer at all if every person is trying to be productive, but is sacrificing essential pieces of what makes us human to get there? 

References: 

(1)          Kjærsgaard, T. Enhancing Motivation by Use of Prescription Stimulants: The Ethics of Motivation Enhancement. AJOB Neurosci. 2015, 6 (1), 4–10.

(2)          Chatterjee, A. Cosmetic Neurology: The Controversy over Enhancing Movement, Mentation, and Mood. Neurology 2004, 63 (6), 968–974.

(3)          Ilieva, I. P.; Farah, M. J. Enhancement Stimulants: Perceived Motivational and Cognitive Advantages. Front. Neurosci. 2013, 7.

(4)          Lucke, J. C.; Bell, S.; Partridge, B.; Hall, W. D. Deflating the Neuroenhancement Bubble. AJOB Neurosci. 2011, 2 (4), 38–43.

(5)          Smith, M. E.; Farah, M. J. Are Prescription Stimulants “Smart Pills”? The Epidemiology and Cognitive Neuroscience of Prescription Stimulant Use by Normal Healthy Individuals. Psychol. Bull. 2011, 137 (5), 717–741.

(6)          Vrecko, S. Just How Cognitive Is “Cognitive Enhancement”? On the Significance of Emotions in University Students’ Experiences with Study Drugs. AJOB Neurosci. 2013, 4 (1), 4–12.

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Strong, K. (2015). Adderall as a Motivational Enhancer. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2015/04/adderall-as-motivational-enhancer.html

The New Normal: How the definition of disease impacts enhancement

We’ve all been there. It’s exam week of your junior year of college
with two papers due the day after a final. You’re a new faculty member with a
semester of lectures to prepare and a lab to get started. You’re a tax
accountant and it’s early April. There is simply too much to do and not enough
hours in the day to get it all done while sleeping enough to keep your brain
working like you need it to. In that situation, where do you stand on cognitive
enhancement drugs? Most of us wouldn’t hesitate to grab a cup of coffee but
what about a caffeine pill, or a friend’s Adderall? Many discussions about
cognitive enhancement eventually come down to this question: where do we draw
the line? Currently most of the cognitive enhancers that create unease for
ethicists and the general public alike are prescription drugs that were
originally meant to treat conditions recognized as out of the realm of “normal”
such as diseases or deficits. Therefore, a key step in deciding where we should
stand on the acceptability of cognitive enhancement is to determine what is
normal and what needs to be medically treated. I’ll argue that one reason there
is so much gray area in the enhancement debate is that delineating normal from
diseased – particularly in the brain – is hardly a black-and-white matter.



Why does the definition of disease matter?
Enhancement is typically defined relative to normal abilities. Anjan Chatterjee of the
University of Pennsylvania suggested that “Therapy is treating disease, whereas
enhancement is improving “normal” abilities. Most people would probably agree
that therapy is desirable. By contrast, enhancing normal abilities gives pause
to many.”¹ However, many neuroethicists have wrestled with clearly
defining enhancement^2,3. The director of Emory’s Center for Ethics, Paul Root Wolpe argued
(2002) that the enhancement debate centers on the ability of substances or
therapeutics to directly affect the
brain in ways that are not necessary to restore health and, certainly, to date
the cognitive enhancement debate has focused primarily on pharmaceuticals, many
of which are approved to treat disorders but can have effects on healthy
individuals as well. Perhaps the best examples of this are methylphenidate
(Ritalin) and modafinil
(Provigil) which are prescribed for attention deficit hyperactivity disorder
(ADHD) and narcolepsy respectively, but are increasingly being used by students
and professionals to boost cognitive performance at school and in the workplace^3-5.

From nytimes.com

Although drugs such as methylphenidate and
modafinil do not directly increase IQ, this measure of “intelligence”, albeit
somewhat controversial⁶, provides another useful
example of the distinction between treatment and enhancement. IQ is scored
relative to the median performance on a given test, set at 100. This means that
because IQ is normally distributed throughout the population, every 15 points
above or below that mark represents one standard deviation. Therefore 95% of
the population should fall within two standard deviations of the mean and score
between 70 and 130. Intellectual disability is defined by a score that is far
to the left on the bell-shaped distribution and, by these standards, it would
be impossible for a large fraction of the population to fall into this category
because the median would then shift[a]. Enhancement,
in terms of IQ, would be a potential improvement within the typical IQ range or
above it. As ethicist and philosopher Julian Savulescu points out, increasing an individual’s IQ from 60-70 would be
considered treatment for a disease but making the same jump from 70-80 is
enhancement since the initial score is already within the normal range².
This is not simply a matter of semantics because, while no currently available
drugs can boost IQ like this, they are frequently being used for other, perhaps
more tangible, cognitive effects. A poll in Nature
found that more than 1 in 5 respondents under the age of 35 have used drugs
explicitly for cognitive enhancement⁷ and
experts expect these numbers to continue to climb^4,8.




In a competitive
setting such as a large undergraduate class that is graded on a “curve”, a
student’s grade is dependent not just on her performance but on how it ranks
among her classmates. Therefore using a so-called study drug without a medical
need could be considered cheating and, if it is a prescription drug it would be
illegal. In fact, Duke University’s student ethics
guide explicitly labels “the unauthorized use of prescription medication
to enhance academic performance” as cheating. Therefore, in some cases patients
have an incentive to define themselves as diseased and a natural way to
circumvent issues of legality and social acceptability is to obtain a
prescription. While it is not known exactly how common this approach is, diagnosis
for ADHD has increased dramatically in recent years. One study found that
outpatient treatment for ADHD increased roughly four-fold in a large cohort
from 1987-1997 ⁹ and
another, more recent study from the CDC, found a nationwide 42% increase in
ADHD diagnosis from 2003 to 2011¹⁰. There
are many reasons for this increase, which likely include a better understanding of
the disorder but, as some have
point out, this increase coincides with policy changes that allow individuals
with intellectual disabilities to be tutored and granted extra time on exams.
These benefits, in addition to the increasingly common knowledge that ADHD
medications can improve concentration even in healthy users, may make it seem
like there is no downside to a diagnosis and might in turn incentivize parents
and students to seek out physicians willing to write prescriptions without
rigorous examinations. In addition, physicians have the ability to prescribe
drugs off-label (in ways not explicitly approved by regulatory agencies) and do
so commonly. A prime example of this practice is modafinil, a drug that is
approved in the US for sleep disorders such as narcolepsy but was found to be
prescribed for off-label indications nearly 90% of the time from 2002-2009⁵.




Disease may not just be defined by physicians,
or demand from patients, but also on the supply side by drug makers themselves
who readily take advantage of the opportunity for direct to consumer marketing in the
US (New Zealand is the only other developed country that allows this practice).
Indeed, a drug has little value to any company unless there is a market for it
and one approach is to convince the public that a common nuisance or
frustration (think shyness) is actually a disease (e.g. social phobia). Wolpe
(2002) noted that, “what medicine chooses to treat is defined as disease, while
altering what it does not treat is enhancement” however I think the inverse is
also true, that whatever positive effects medicines have in the absence of a known
deficit could also be considered enhancement. Pharmaceutical companies have
been branding
diseases (or some say disease
mongering) for decades with the hope that changing the definition of normal and
diseased can broaden the market for their stable of drugs under patent. A
recent overt example of this practice is the ubiquitous marketing of
testosterone supplements to remedy “low T” 
(hypogonadism), a disorder that was once thought be a rare condition but is now
suggested to afflict most middle-aged men (if the ads are to
be believed). Unfortunately, unnecessarily manipulating this hormone can have
serious life-long health consequences, some of which the FDA is now investigating

Wolinsky, 2005

By contrast, an area where the definition of
disease may be less important is in age-related cognitive decline. How much
mental ability needs to be lost in elderly individuals before the line is
crossed into cognitive impairment and who gets to make that decision? If drug safety
could reasonably be established then perhaps adults at that stage in life
should be able to choose to use cognitive enhancers whether or not their
deficits reach clinical thresholds. One could make the case that drugs could
actually help to preserve
authenticity, another controversial area and a major concern with their use in
children and young adults. To reiterate the difficulty in diagnosing disorders
of the brain, it is debatable whether even a profoundly debilitating disease
such as Alzheimer’s can be definitively diagnosed without
post-mortem tissue examination.




Diagnostic
practices are sure to change, though, and it is likely that in the near future
researchers will discover new biomarkers for neuropsychiatric disorders. However,
this will not necessarily make it any easier. It is doubtful that any biomarker
will give a clear yes-or-no, black and white indication. As to whether a biomarker
indicates something is “out of the range of normal” is also subject to the
moving target of what humans consider “normal”. Instead, a normal range will
need to be determined, but by whom? Given what is at stake it is hardly cynical
to suggest that drug makers will have a significant role and, in the end,
physicians will continue to be able to prescribe approved drugs for off-label
use⁵. In the
meantime, instead of immediately accepting that drugs with cognitive enhancement
potential are always permissible with a doctor’s diagnosis, there should be further
discussion between physicians, regulators, ethicists and disability
advocates about how that diagnosis is made. This determination will have
widespread implications for healthcare providers, insurance companies, drug
companies, and the general public and society who are struggling to determine
what constitutes “the good life” and ultimate human flourishing.






References

 


1) Chatterjee,
A. Cosmetic neurology: the controversy over enhancing movement, mentation, and
mood. Neurology 63, 968-974 (2004).




2) Savulescu, J. Justice, fairness, and
enhancement. Ann Ny Acad Sci 1093, 321-338, doi:DOI
10.1196/annals.1382.021 (2006).




2) Wolpe, P. R. Treatment, enhancement,
and the ethics of neurotherapeutics. Brain
Cogn 50, 387-395 (2002).




3) Cakic, V. Smart drugs for cognitive
enhancement: ethical and pragmatic considerations in the era of cosmetic
neurology. Journal of medical ethics 35, 611-615,
doi:10.1136/jme.2009.030882 (2009).




4) Greely, H. et al. Towards responsible use of cognitive-enhancing drugs by the
healthy. Nature 456, 702-705, doi:10.1038/456702a (2008).




5) Penaloza, R. A., Sarkar, U., Claman,
D. M. & Omachi, T. A. Trends in on-label and off-label modafinil use in a
nationally representative sample. JAMA
internal medicine 173, 704-706,
doi:10.1001/jamainternmed.2013.2807 (2013).




6) Weinberg, R. A. Intelligence and Iq -
Landmark Issues and Great Debates. Am
Psychol 44, 98-104 (1989).




7) Farah, M. J. et al. Neurocognitive enhancement: what can we do and what should
we do? Nature reviews. Neuroscience 5, 421-425, doi:10.1038/nrn1390 (2004).




8) Maher, B. Poll results: look who's
doping. Nature 452, 674-675, doi:10.1038/452674a (2008).




9) Olfson, M., Gameroff, M. J., Marcus,
S. C. & Jensen, P. S. National trends in the treatment of attention deficit
hyperactivity disorder. The American
journal of psychiatry 160,
1071-1077 (2003).




10) Visser, S. N. et al. Trends in the parent-report of health care
provider-diagnosed and medicated attention-deficit/hyperactivity disorder:
United States, 2003-2011. Journal of the
American Academy of Child and Adolescent Psychiatry 53, 34-46 e32, doi:10.1016/j.jaac.2013.09.001 (2014).






[a] Not to mention the “Flynn effect", which describes the phenomenon of increasing IQ worldwide over time.






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Purcell, R. (2014). The New Normal: how the definition of disease impacts enhancement.  The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2014/07/the-new-normal-how-definition-of.html

Physical vs. Cognitive Alterations: Is All Fair in the World of Anti-Aging Enhancement?

On March 28, Dr. Rommelfanger, Assistant Director of Emory's Neuroethics Program, gave a talk to the Nu Rho Psi group about the ethics of neuroenhancement technologies. These technologies can be anything from Adderall to interventions that raises IQ. This talk got me thinking about how the normal human aging process is critical in the way that a person views themselves and others. 

Aging now battled with complex technologies. Across the world, doctors routinely perform appearance altering operations, even to the point of giving someone an entirely new face (like this man), which certainly come with psychological consequences. While face transplants are an extreme example, other cosmetic procedures, like Botox injections to relax wrinkles, are performed millions of times a year.  But what about procedures to alter cognitive function? Is neuroenhancement technology ready to become mainstream, or is there some inherent feeling that altering the brain is off limits?

 In the view of Arthur Caplan (Director of the Center for Bioethics at UPenn), "Messing with the brain is unnatural because the brain is the seat of who we are. To change it is to change our identity."¹ Loss of identity is a frightening prospect. As the population ages (the median age in America jumped almost 2.5 years from 1990-2000)² and technology progresses, the interest in brain enhancement for the purposes of retaining cognitive abilities known to decline with age will grow. Is altering our brain function really much bigger of a step from altering our physical bodies, or is it mostly fear of the unknown?

Francis Fukayama states, in a speech called “Our Post-human Future”, “Human rights are based on a certain understanding of human nature.”³ Neuroenhancements are often understood as bestowing an unfair advantage on those who are enhanced in ways that plastic surgery could not, to the point of potentially changing this “human nature”. But can’t physical features have profound effects on “human nature”? In a study done by Timothy Judge and Daniel Cable, it was found that taller people make more money at an average of almost $800 per year per inch above average.⁴ Isn’t this an unfair advantage?

  In terms of neuroenhancements, even caffeine could be seen as enhancing your brain function, yet coffee is a widely accepted and properly consumed substance. When I have a long paper to write, I can be seen in the library with a gigantic cup of coffee feverishly typing away – is keeping myself awake and alert giving me an advantage over others (or cheating), and if so, should it be banned? What if I were an executive in my 60s using supplements to keep my brain “young” to hold onto my career? As Fukuyama points out, society moves in a generational pattern, and if six generations of people are competing for the same jobs, this will seriously change the fabric of society and competition. But isn’t life in general full of unfair advantages (money, physical traits, etc.)…how do we say what is “fair” or “natural” and what is not?

Both plastic surgery (aesthetic) and neuroenhancements (cognitive) are used as a way to battle the aging process, a huge determinant of identity. Humans are mortal, and while we are all faced with this as reality, some prefer to think that mortality doesn’t have to limit our existence. There are even individuals, like Ray Kurzweil⁵, a leader of the transhumanism movement, who believe that the time is coming when people won’t have to die at all because computers will have progressed to a point where we can upload our minds onto them. 

This may seem extreme, but it is unsurprising that many would seek to slow the aging process, whether by appearing younger or attempting to keep the brain functioning at a high level.

We have all been bombarded with images of youth and beauty, urging us to buy the latest anti-aging products. Plastic surgery has a large client base of those seeking the latest in wrinkle treatment, and even something as simple as hair dye is a weapon in the fight to appear young. In the United States alone, over 119,000 facelifts were performed in 2011 (up 5% from 2010)⁶, and this and other age-defying procedures like Botox have been increasing rapidly throughout the world.⁷

In Western society, youth is highly valued, and age is often viewed as a sign of weakness or uselessness.⁹ However, East Asian cultures have traditionally revered their elders and looked to them as a source of wisdom.⁸ While many Asian countries, like South Korea and Japan, have been quick to embrace Western culture and anti-aging aesthetics like plastic surgery, it seems their reverence for the aged and the process of aging may lead to a decreased likelihood to try brain enhancements.¹⁰ Why would someone who already possesses the wisdom and respect that comes with age need an anti-aging upgrade?

Countless vitamins and supplements claim to boost brain function, and most advances in medicine are sought in the diseases of aging. Invasive surgical processes already being attempted for diseases like Parkinson’s (deep brain stimulation)¹¹ and Alzheimer’s (implanting genetically modified cells into the brain)¹². It may not be that much of a stretch to see a world in which all aging people, not just those with diagnosable diseases, may seek treatment to keep their brains “young”. Cognitive decline will no longer be seen as “normal”.

Neuroenhancement is simply unnatural, you may say. That it may be, but humanity has been fighting nature for a long time. Have no hair? Wear a wig. Vision poor? Here are some glasses. Can’t hear? Cochlear implants might be just the thing for you. The problem with this line of reasoning is that all of these things can be seen as technologies designed to grant a person “normal” abilities, even if they fit in the category of neuroenhancements. We assume that any given human will “normally” possess the ability to see; we do not assume that they will have a genius level IQ or the ability to live to age 200. With the development of neuroenhancements, might it be possible that we create a world in which non-enhanced people are considered abnormal or that enhanced older people are being “enabled”?

Many groups are quick to attack neuroenhancements as technology to be feared and censored. For instance, Leon Kass wonders whether we will doom future generations to become slaves to machines and whether we fully recognize the immense potential for evil that some of these technologies can create.¹³ In terms of brain-enhancing drugs, some doctors wonder whether or not the safety of long term use has been adequately tested.¹⁴ While these are legitimate concerns deserving of careful thought, I believe most of this skepticism can be largely attributed to a fear of the unknown. Most of us have seen the movies where robots or genetically engineered humans take over the world (Gattaca, I, Robot), leaving the “normal” people at best outcasts and at worst akin to some kind of lowly beast in the eyes of those in power. 

While some may be frightened by these prospects and the idea of enhancing technology, others might be tempted to run full speed ahead into the world of brain enhancements. The technologies with which humans can transform their bodies are major and varied, and many are already being employed; should enhancement of the brain really be off limits?



--Mia Michalak

Nu Rho Psi Member, Emory Neuroscience and Behavioral Biology Student









Want to cite this post?


Michalak, M. (2012). Physical vs. Cognitive Alterations: Is All Fair in the World of Anti-Aging Enhancement? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/physical-vs-cognitive-alterations-is.html

References

http://www.cognitiveliberty.org/news/xtian_sci_enhancement.html (1)

http://usgovinfo.about.com/library/weekly/aa051801a.htm(2)

https://www.carnegiecouncil.org/resources/transcripts/138.html/:pf_printable(3)

http://www.apa.org/monitor/julaug04/standing.aspx (4)

http://www.kurzweilai.net/ (5)

http://www.plasticsurgery.org/News-and-Resources/138-Million-Cosmetic-Plastic-Surgery-Procedures-Performed-in-2011.html (6)

http://www.prnewswire.com/news-releases/worldwide-plastic-surgery-statistics-available-for-the-first-time-100248404.html (7)

http://www.asiamedia.ucla.edu/article.asp?parentid=11693 (8)

http://www.cifs.dk/scripts/artikel.asp?id=678&lng=2 (9)

http://cmbconference2012.wordpress.com/2012/02/24/fpr-interviews-cultural-psychologist-conference-session-chair-shinobu-kitayama/ (10

http://www.nejm.org/doi/full/10.1056/nejmoa060281#t=articleTop (11)

http://health.ucsd.edu/news/2001/04_09_Tusz.html (12)

http://www.mindfully.org/GE/Moral-Genetic-Technology-Kass18mar99.htm (13)

http://www.tandfonline.com/doi/full/10.1080/13554794.2011.588174 (14)

Psychostimulants in preschoolers: Panacea or Pandora's Box?

Victoria became pregnant at a young age. During her pregnancy, she was unable to consistently make responsible choices for herself and her developing child, often indulging in alcohol and drugs. As a result, her son Brian was born prematurely at 7 months. By the time Brian entered preschool, he became increasingly difficult for Victoria and his teachers to control, his interactions with other children at times violent and aggressive. Desperately trying to manage Brian’s outbursts, Victoria confides in a child psychiatrist who puts Brian on Ritalin. Within a couple of months, Brian’s outbursts subside, and much to everyone’s relief (Brian’s included), he is now able to sit through his preschool classes with limited distraction. He begins to enjoy relating with other kids and no longer receives negative attention at school. Several years later, Brian, now a very diminutive 9 year-old, writes a paper for a class assignment in which he suggests that everyone should have treatment like him to “make them behave,” and that “all kids with broken brains should have them fixed, too.” When Victoria learns of this, she speaks with Brian, who says he is confused why some kids can “be good without pills,” and wonders if people would “still love him if he stopped taking his.”¹ 

To some, this story tells of the triumph of administering drugs like Ritalin to children with certain behavioral profiles, such as attention-deficit/hyperactivity disorder (ADHD). Before being treated, Brian is uncooperative, anti-social, and unresponsive to linguistic persuasion. His behavioral disposition persisted and continued to worsen before treatment, and his prenatal exposure to toxins suggests that Brian may have suffered neurodevelopmental abnormalities that contributed to his social dysfunction. By comparison, Brian’s treatment is a successful attempt to bring him “up to speed” with his peers: he now exhibits self-control, can develop meaningful relationships, and attends to his schoolwork.

However, to others, this story highlights concerns about identity formation, self-worth, and growth retardation in drug-treated children. The issue is that Brian has begun to realize how he acts, what he thinks, and how he feels are all in some way a result of the treatment, and that this sets him apart from his “good” peers. Brian’s perception of himself in relation to the world around him has been changed in a fundamental way that will shape his identity as he matures. The hope is that Brian’s caretakers will support his healthy exploration of these concepts and reassure him that his worthiness does not depend on drugs. Also of concern is Brian’s stunted growth, which may be a result of long-term Ritalin treatment.

As a whole, Brian’s story illustrates both the successes and perils of psychopharmacological treatment in very young children. With respect to social functioning, there may be clear, long-lasting improvements for some with ADHD; others may fail to respond, or worse, experience adverse side effects. This brings up the issue of safety, which has been studied to a very limited extent in young children and begs the following question: “Despite their psychosocial benefits, how safe are these drugs for the vulnerable brains and growing bodies of preschoolers?” In order to address this question, I’ll provide an overview of the current body of research into the safety and efficacy of these drugs, along with current trends in ADHD diagnosis and treatment.

Methylphenidate, often referred to by its trademark name Ritalin, and amphetamine (trademark Adderall) are by far the most commonly prescribed drugs used to treat ADHD in preschoolers 4-5 years of age. Both drugs are psychostimulants, meaning they can enhance alertness, and have been shown to reduce classical ADHD symptoms of hyperactivity and inattention. While the exact data on how many prescriptions have been issued to preschoolers alone are unclear, the CDC estimates that just over 4% of all children aged 4-10 took psychostimulants as of 2007². Trends have been increasing since the early 1990’s and can be expected to continue. Aligned with this expectation is the American Academy of Pediatrics’ (AAP) October 2011 release of new clinical practice guidelines supporting the use of psychostimulants in 4 and 5 year-olds³, which the CDC also endorses⁴. The AAP claims, “there is now emerging evidence to [prescribe to] preschool-aged children.” What is this emerging evidence, exactly?

Of the two psychostimulant drugs most commonly prescribed to preschoolers (and there are a handful of others), only Adderall has received Food and Drug Administration (FDA) approval for use in children this young (also keep in mind that a clinician may prescribe an FDA-approved medication to treat basically any condition in any person, a practice known as “off-label” usage; so, prescribing almost any drug on the market to preschoolers is fair game). One might expect that FDA approval would be based on studies illustrating that Adderall is safe for preschoolers; however it is worth noting that no double-blind, placebo-controlled clinical trial of Adderall in preschoolers has ever been conducted. This basically means that tens if not hundreds of thousands of children are currently taking a drug without most stringent science to back it up, which even the AAP notes has “little evidence to support its safety and efficacy.” On the other hand, Adderall has been studied and deemed safe for older children (6+ years); however, studies have shown decreased drug metabolism and clearance in preschoolers, making the FDA’s extrapolation problematic⁵.

Ritalin’s effects in preschoolers are better characterized, though the FDA has not officially approved its use in children this young. While a dozen or so studies have examined the effects of Ritalin in preschoolers, only one double-blind, placebo-controlled trial has been carried out. This study, known as the Preschool ADHD Treatment Study (PATS) was completed in 2006 and forms the basis for the AAP’s statement that “methylphenidate is safe and efficacious for children in this age group.” The findings of PATS are encouraging and corroborate the AAP’s claims of efficacy: nearly 2/3 of the 140 children who received 10 months of continual treatment had improvements in ADHD symptomatology⁶. However, some safety concerns were raised. A small number of subjects dropped out of the study due to adverse side effects, but more concerning was that the Ritalin-treated group experienced 20% less than expected height gain, and 55% less than expected weight gain compared to their unmedicated peers. A similar study in older children suggested that growth-suppressed children never catch up to their unmedicated peers⁷, and this effect could be even more pronounced when medication is begun earlier in development.

It is clear that additional research studies are necessary. The aforementioned trials only begin to address issues of safety and efficacy, and given the (increasing) prevalence of ADHD diagnoses, the AAP’s recommendation to its 60,000 clinicians to provide drug treatment seems premature. It is important to mention that the AAP recommends Ritalin as a secondary treatment option; behavioral therapy is first, and ideally combines parent, teacher, and peer-based programs. However, the CDC indicates that over 2/3 of children with ADHD currently receive drug treatment⁸, and a recent study found a 4.9-fold increase in the rate of doctor’s office visits resulting in both an ADHD diagnosis and psychostimulant prescription over the past 18 years⁹. So, either the behavioral therapy isn’t working, or is being bypassed altogether in favor of pills. Keep in mind that behavioral therapy requires a large time commitment by parents and teachers, and the benefits are often not seen for months. In contrast, pharmacotherapy requires relatively little time and energy, and the effects on a child’s behavior may be seen within days. Obviously, the latter option is far more accessible and alluring.

For Brian, we can only hope that his caretakers will continue to closely monitor his behavior and make the best possible decisions with respect to his course of treatment, whether or not that necessitates the use of Ritalin. But not all kids are so fortunate. The reality is that many children are not surrounded by engaged parents and educators willing to put forth the time, effort, and patience required for behavioral therapy. These children, such as those in foster care or from underserved communities, may be particularly vulnerable to being unnecessarily medicated, over-medicated, or both. Evidence for this comes as early as 1999, where data from the Michigan Medicaid system showed that 57% of children aged 3 and younger with ADHD were treated with as many as 22 different medications in 30 combinations and monitored less than every 3 months¹⁰. Although most prescriptions written for preschoolers are psychostimulants, off-label use of antidepressants and antipsychotics is prevalent, and these drugs often have never been tested in young children.

We all want our children and adolescents to thrive and develop into well-balanced, happy adults. This motivation has driven more than two decades of research into ADHD diagnosis and treatment. But it is exceedingly important that we proceed with caution and not be clouded by delusions that a drug, whether now or in the future, will act as panacea. The neurobiological underpinnings of ADHD are complex and vary greatly across individuals. As we have seen, considerable variation also exists in terms of drug sensitivity and metabolism. So while some children have and will continue to benefit greatly from psychostimulants, others will not. Consequently, it is imperative that as ADHD research progresses, scientists and clinicians devote time and resources to developing multimodal treatment strategies that blend behavioral therapy with pharmacotherapy and can be tailored to the individual needs of the child. Multimodal strategies are recognized as the most effective form of treatment for ADHD in children¹¹. On the social level, we must have adequate safeguards in place to advocate on behalf of children most vulnerable to overmedication. We should also be prepared to confidently address the inevitable questions of identity and self-worth that our children will quarrel with, as well as to retrospectively defend our decision to medicate them.

--Jordan Kohn

Emory University

Neuroscience Graduate Program

Want to cite this post?

Kohn, J. (2012). Psychostimulants in preschoolers: Panacea or Pandora's Box? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/psychostimulants-in-preschoolers.html

1. This story was adapted from Stein Z, Chiesa BD, Hinton C, Fischer KW. “Ethical issues in educational neuroscience: Raising children in a brave new world.” The Oxford Handbook of Neuroethics. Ed. Illes J and Sahakian BJ. New York: Oxford University Press, 2011. 803-819.  



2. Visser SN, Bitsko RH, Danielson ML, Perou R, and Blumberg SJ. (2010) Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children – United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44): 1439-1443. 



3. Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. (2011) Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 128(5): 1007-1022.



4.Recommendations from the American Academy of Pediatrics (AAP). http://www.cdc.gov/ncbddd/adhd/guidelines.html. Accessed 28 Mar 2012.



5. Wigal SB, Gupta S, Greenhill L, Posner K, Lerner M, Steinhoff K, Wigal T, Kapelinski A, Martinez J, Modi NB, Stehli A, Swanson J. (2007). Pharmacokinetics of methylphenidate in preschoolers with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 17 (2): 153-164.



6. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skrobala A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. (2006) Efficacy and Safety of Immediate-Release Methylphenidate Treatment for Preschoolers with ADHD. J Am. Acad. Child Adolesc. Psychiatry. 45(11):1284-1293.



7. Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, Hechtman L, Epstein JN, Pelham WE, Abikoff HB, Newcorn JH, Molina BS, Hinshaw SP, Wells KC, Hoza B, Jensen PS, Gibbons RD, Hur K, Stehli A, Davies M, March JS, Conners CK, Caron M, Volkow ND. (2007) Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 46(8):1015-27.



8. Attention Deficit/Hyperactivity Disorder: Data & Statistics in the United States. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 1 April 2012.



9. Sclar DA, Robison LM, Bowen KA, Schmidt JM, Castillo LV, Oganov AM. (2012). Clinical Pediatrics. E-pub ahead of print. Accessed 1 April 2012.



10. Rappley MD, Mullan PB, Alvarez FJ, Eneli IU, Wang J, Gardiner JC. (1999). Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children. Arch Pediatr Adolesc Med. 153(10): 1039-1045.



11. National Resource Center on ADHD: Diagnosis & Treatment. http://www.help4adhd.org/en/treatment/treatmentoverview. Accessed 1 April 2012.