Medications that improve mental functioning are already in use. The medical community needs to respond to the ethical, business and other issues they raise.
Mind enhancement is nothing new to our species. Written language, printing and the Internet, deliberate exercise, nutrition and sleep, brain stimulation and prosthetic brain chips, education, good health habits, and information technology are all ways that humanity has devised to improve itself. Not that these are necessarily morally equivalent with the use of drugs for the same purpose. But the commonly made argument that drug-based enhancement is "unnatural" disregards the fact that our lives are already deeply unnatural in terms of shelter, food, clothing, transportation, medical care and so on. So why draw an arbitrary line at mind-enhancing drugs?
In H&HN Weekly of Feb. 10, Kit Greene and I wrote about technological advances in "Mental Superhealth," in which we discuss applications of neuroimaging and computational biology that will lead to enhancements such as robotic knees and devices that enable the blind to see with their ears. Today I will cover medications for cognitive enhancement.
The drugs most commonly used for cognitive enhancement are Ritalin (methyphenidate) and Adderall (mixed amphetamine salts), prescribed mainly for the treatment of attention deficit hyperactivity disorder (ADHD). The drugs increase executive functions in patients and most healthy normal people, improving their ability to focus, manipulate information in working memory and control their responses.
Modafinil (Provigil), approved for the treatment of fatigue caused by sleep disorders, is also prescribed off label for neuropsychiatric and medical conditions involving fatigue as well as for healthy people who need to stay alert and awake when sleep deprived, such as soldiers, fighter pilots and physicians on night call. Modafinil also appears to enhance executive function, particularly inhibitory control, in rested healthy adults.
In their Nature article, Henry Greely et al. (see "Towards responsible use of cognitive-enhancing drugs by the healthy," Dec. 7, 2008) call for a presumption that mentally competent adults should be able to use such drugs as these to enhance their minds. The authors acknowledge and address the risks and ethical concerns as follows:
Safety. There are no safety and effectiveness trials for off-label uses of the aforementioned drugs, including enhancement uses. Evidence needs to be continually collected to evaluate the risks and benefits of cognitive enhancement.
Freedom from coercion to enhance. Except in specific circumstances for specific occupations, justified by substantial gains in safety, no one should be forced to take such drugs. (Children, however, could be a special case.)
Fairness. Policy governing the use of cognitive enhancement in competitive situations should avoid exacerbating socioeconomic inequalities, and should take into account the validity of enhanced test performance.
These concerns may not be enough to deter buyers and sellers of enhancement products. Cognitive enhancement is a disruptive innovation that could have a profound effect on human life in a future already promising greatly extended life spans and careers. It is therefore too important to leave to the value-neutral market.
A rational, evidence-based policy informed by a wide array of relevant experts and stakeholders is needed. Greely et al.propose four types of policy mechanisms:
An accelerated program of research to build a knowledge base concerning the usage, benefits and associated risks of cognitive enhancement treatments taken by healthy individuals.
Professional guidelines for professions that have a role in dispensing, using or working with people who use cognitive enhancers. These include physicians, particularly those in primary care, pediatrics and psychiatry who are most likely to be asked for cognitive enhancers.
Public education to increase understanding of cognitive enhancement. This would be provided by physicians, teachers, college health centers and employers, similar to the way information about nutrition, recreational drugs and other public-health information is now disseminated.
Laws and regulations should be amended to take account of emerging social norms and information about safety. Drug law is one of the most controversial areas of law, and although it would be naive to expect rapid or revolutionary change in the laws governing the use of controlled substances, these laws should be adjusted to avoid making felons out of those who seek to use safe cognitive enhancements. Regulatory agencies should allow pharmaceutical companies to market cognitive-enhancing drugs to healthy adults, provided the companies have supplied the necessary regulatory data for safety and efficacy.
Humanity cannot help but explore new territory, dangerous or not. The important question is not whether but how we should control the exploration and minimize the risks.
That question is the very one for which Greely et al. provide a rational answer, and in so doing they have performed a public service in raising the issues and suggesting a way forward. The health care professions need to keep the ball rolling.
David Ellis is corporate director of planning and future studies at the Detroit Medical Center and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. Mr. Ellis is also a regular contributor to H&HN Weekly.
This article first appeared in the on October 26, 2009 in HHN Magazine online site.