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Put down the smart drugs – cognitive enhancement is ethically risky business

Cognitive enhancers could join coffee, pain killers and antibiotics as an accepted – and expected – mode of self-improvement. Flickr/cosmo flash, CC BY-SA

Cognitive performance enhancers promise to deliver a better version of ourselves: smarter, more alert and more mentally agile. But what if such enhancement was no longer a personal choice but a socially and legally enforced responsibility? In the final instalment of Biology and Blame, Nicole A Vincent and Emma A. Jane explore the risks of normalising this emerging trend.

In Australia and all around the world, students, academics and professionals of various stripes are increasingly experimenting with new cognitive enhancement technologies to boost their memory, attention, reflexes, clarity of thought and ability to function well with little sleep.

In many cases, this involves the repurposing of medications that have previously been used to help the sick become “normal”, rather than to boost the well into some sort of superhuman sphere. These include controlled drugs such as Ritalin (a central nervous system stimulant usually prescribed for hyperactivity and impulse control), modafinil (a medication used for increasing wakefulness in patients with conditions such as narcolepsy) and donepezil (used to treat dementia).

Interest is also growing in transcranial direct current stimulation (tDCS) devices, which stimulate the brain using electricity drawn from nine-volt batteries. These largely unregulated and under-tested devices are said to sort out everything from depression to poor sports performance. But there are concerns that the DIY use of such “electroceuticals” may result in at-home users zapping their brains in ways that harm rather than help.

Because these techniques and technologies are new – or at least are being put to novel use – the issues that tend to get most attention in academia and in the media relate to their effectiveness and safety.

The jury is still out on which of these techniques and technologies work, for whom they work, and how and how well they work. There is also breathtaking disagreement about such fundamental issues as: what percentage of people are using them; whether their effects are best described as “enhancement” or only as “treatment”; and what side effects they might produce.

The jury is still out on whether, or how well, cognitive enhancement works. Julia Shore, CC BY-NC-ND

Several recent studies report around a 30% improvement in language learning by subjects who used modafinil or tDCS over those who did not.

Other researchers, however, warn that the hype surrounding cognitive enhancement is unhelpful and possibly even dangerous. This, they say, adds to the pressure people already feel to use these technologies, even though claims about their effectiveness and safety are at least premature if not overstated and even outright misleading.

But while safety and effectiveness are indeed important concerns, some ethico-legal issues are even more critical. Let’s imagine, for instance, that modafinil and tDCS turn out to be as effective and safe as the optimistic studies suggest; that they are as relatively inexpensive, innocuous and helpful as all those other prosaic props that regularly help us get through the day (coffee, painkillers and post-work flutes of prosecco, as just three examples).

Despite the benefits, we think there is good reason not to embrace these new technologies: namely, to ensure that cognitive enhancement does not become the new “normal”. Put another way, we don’t want to find ourselves in a scenario where mildly electrifying our brains is no longer considered a personal choice but is instead a socially and legally enforced responsibility. Yet, right now, concerns about effectiveness and safety are all that stands between us and that scenario.

The new ‘normal’

To understand this situation, consider two examples one of us discussed recently at TEDxSydney.

In a clever article written for Limelight Magazine last year, the very talented and accomplished Sydney-based concert pianist Simon Tedeschi writes about how a significant portion of concert musicians nowadays use or feel pressured to use medications called beta blockers. This is to calm their nerves before recitals for jobs, and on stage to deliver the superior performances we have come to expect of them.

Off-label uses of beta blockers began quietly in classical music circles in the late 1970s when small numbers of performers began using these cardiac medications to prevent crippling performance anxiety such as slippery palms, thumping hearts and flute-unfriendly lip quivers.

But, as time passed, increasing numbers of musicians turned to these medications to the point where this practice is becoming a new “normal”. Other concert musicians are increasingly wondering whether they too should start using beta blockers simply to keep up and remain competitive with those who already use them.

Musicians are increasingly using beta blockers to calm their nerves before concerts. Gigi Tagliapietra, CC BY-NC

What was once a choice for a few disadvantaged people is becoming a de facto necessity for all. And this did not occur because anybody intended it to be this way, but simply because of the way in which competition (and audience expectations) works.

A second example comes from three years ago, when members of a Jetstar cabin crew complained to the media that their employer, a Thai company based in Bangkok called Tour East Thailand, was increasingly expecting them to work 20-hour shifts. The crew members were concerned that in the event of an emergency they would be too tired to be able to respond effectively and passengers’ safety could be compromised.

Imagine, though, what might happen in scenarios like this if enhancers such as modafinil turn out to be effective and safe health-wise. Given the enormous pressure on workers to achieve ever-rising levels of productivity, there is a risk that employers might make it a condition of employment that cabin crew use such medications to remain alert for the duration of their shifts.

This would be an industrial relations nightmare: nobody should be expected to enhance themselves just to do their job.

When the debate focuses on effectiveness and safety, it’s too easy to overlook myriad social, political and ethical reasons to say “no” to cognitive enhancement right now. This risks dystopic scenarios where corporations use such medications to save money by demanding superhuman efforts from workers rather than simply employing more staff.

At present, social attitudes towards cognitive enhancement range from fanatical enthusiasm to dismissive scepticism and frightened resistance. But these polarised reactions are likely to disappear once safety, effectiveness and equity of access can be assured.

Our worry is that – at precisely that point – cognitive enhancement will join coffee, painkillers, antibiotics and even smart phones in becoming the commonsensical and expected choice. The burden of proof will have shifted such that everyone will be expected to enhance themselves; justifications will have to be given to explain why we should not comply.

Enhancement as a responsibility

Here is another way to see this point.

Imagine you’re a surgeon about to perform a delicate, difficult, lengthy and ultimately risky operation, and that you could substantially improve your patient’s chances of survival by safely taking a pill that would increase your wakefulness, mental acuity, perceptiveness and ability to stay focused.

Judges are not likely to recognise a duty for surgeons to enhance themselves any time soon. Aleera/Flickr, CC BY-ND

If the pill really were that effective, and if it really had so few side effects, would it be a fait accompli that you should take it? Should you now have to take this pill to give your patients the best chance of recovery and survival? And would you be negligent – perhaps even reckless – if you didn’t take it?

When we are asked about whether we ought to enhance ourselves – and whether we would be responsible for any bad consequences and held responsible under the law if we don’t – it’s much less obvious that the answer should automatically be “yes”.

What we’re concerned about is the slippery slope that might lead from enhancement being a choice to it being a responsibility — that what’s initially freely chosen as a way of bettering ourselves, accomplishing more, or just making life easier and keeping up, may eventually become expected and even required. Sound unlikely? Consider hints by Queensland Health that medical staff might have a duty to fight fatigue by, among other forms of cognitive enhancement, consuming the equivalent of five to six cups of coffee a night.

Despite these sort of caffeine-friendly suggestions, judges are not likely to recognise a duty for surgeons to enhance themselves any time soon. This is a good thing. What’s more, though, if we wish things to stay this way, we may need to resist the temptation to pop pills to enhance ourselves — even if the immediate benefits seem attractive. The long-term consequences may be distinctly unattractive.

Exercising restraint

Advances in science and technology subtly shape our lives by gradually, and often imperceptibly, changing the moral, legal and social landscape. What we expect of ourselves and of one another also changes with the times. It changes with what we think people are capable of doing and what we think is reasonable to expect people to be capable of doing.

If we wish to retain our choice, we may need to resist the temptation to use even safe and effective enhancers.

Despite the benefits, there is a persuasive reason not to embrace cognitive-enhancing technologies. World Bank Photo Collection, CC BY-NC-ND

Or, at least, if the benefits of cognitive enhancement are ultimately worth it, we should keep the conversation going about how to ensure that cognitive enhancement does not just become the new “normal”. We must not allow our expectations to creep upwards and ultimately coerce us collectively into having to enhance ourselves.

This will require intelligent regulation of these exciting – but ethically challenging – new technologies in a way that transcends the current dominance of discussions about effectiveness and safety.

This is the seventh and final article in our series Biology and Blame. Click on the links below to read other pieces:

Part one – Genes made me do it: genetics, responsibility and criminal law

Part two – Irresponsible brains? The role of consciousness in guilt

Part three – Psychiatry’s fight for a place in defining criminal responsibility

Part four – Looking for psychopaths in all the wrong places: fMRI in court

Part five - Why shouldn’t addiction be a defence to low-level crime?

Part six – Natural born killers: brain shape, behaviour and the history of phrenology

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