Morning Joe, Evening Jack

From java to Jack Daniels, we've long accepted our daily cognitive enhancement along with our daily bread

On December 7 the distinguished journal Nature published a thoughtful but surprising essay, "Towards responsible use of cognitive-enhancing drugs by the healthy."

 Among the cosigners were three world-class brain scientists whose work I have followed for decades (Martha Farah, Barbara Sahakian, and Michael Gazzaniga), the journal's editor, and several experts on medical ethics and law.

In it they take up and try to set aside a variety of objections and in the end state categorically, "We should welcome new methods of improving our brain function."

To the argument that it is unnatural, they reply that so are clothing, shelter, food, and medical care. One might say that it is human nature to make and use unnatural things. Why not enhancement drugs?

To the claim-by analogy to the enhancement drugs used in sports–that it is cheating, they point out that that is cheating because it is against the rules; there are no such rules in the cognitive sphere. Also, in sports competition is of the essence of the activity.

For cognitive activity, there is inherent value in what is produced or achieved-a surgical operation, a computer program, a new economic theory, a proper accounting of a year of business, a college education. There is competition, but it is ancillary, not the core purpose of the effort.

And to the assertion that it is drug abuse, they answer that abuse is a matter of law and regulation; they argue that enhancement drugs should be regulated and legal.

What are they? Lately, methylphenidate (Ritalin) and amphetamine salts (Adderall) for improving attention and the newer agent modafanil (Provigil) for combating sleepiness. Of course, if you have attention deficit-hyperactivity disorder (ADHD) or narcolepsy (dangerous daytime sleep episodes), your doc whips out her prescription pad (or hand-held) and writes you for the drug. You get a diagnostic label with an official number and you may even get partly reimbursed.

But what if you just have TAT (Tired All the Time) or daydreams? Those, alas, are not diagnoses. So: no drug? Well, certainly no reimbursement, unless your doc stretches the diagnostic category, and the truth.

This is commonly done, and it poses a moral problem: Is the doctor cheating the insurer? Is she protecting herself from possible prosecution should you have an adverse effect? The authors' claim of "maximum benefit, minimum harm" does not always hold true. We are in a moral gray area. But why don't I think it's just wrong?

For one thing, there is such a thing as an "off-label" use. The FDA approves a drug for one purposes, but doctors still have enough autonomy to read the research literature and make their own judgments about whether they should prescribe it for something not officially approved. Responsibly done, this is both legal and ethical.

But what if there is no diagnosis at all?

Although it is not (directly) a mental medication, growth hormone was instructive. At first it was expensive and given only to short children with a deficiency of growth hormone. Diagnosis: short stature due to growth hormone deficiency. Treatment: growth hormone. Result: inches of extra height.

But it turned out that growth hormone increased the final height of equally short children with normal hormone levels. What to do? Our society says taller is better, up to a point, at least for boys. Many doctors said, treat them. But then, what do you say when confronted with a really talented school basketball player who is tall, but not tall enough?

You get the idea. Now consider Prozac and its cousins. When this new class of anti-depressants came along, they had far fewer side effects, and were therefore prescribed more widely. The line between sad and depressed moved, and many people were treated who perhaps did not quite merit the traditional diagnosis of depression.

And now, we have Adderall and Provigil traded among law students and hospital interns like baseball cards. Not to get high, just to stay awake, concentrate, perform. And this is just the beginning. Several drugs available for improving mental function in Alzheimer's patients are the tip of an iceberg of future possibilities for enhancing memory, problem solving, and other brain functions.

To be sure, they are not natural. But neither are coffee, wine, and many other mind-altering (and up to a point, mind-improving) substances that have been a part of the world's cultures for thousands of years. The new ones are just substances that need prescriptions.

There are important ethical issues. Under our present (sickeningly unequal) health care "system," these drugs will increase inequality. Also, what do we know about the threats to human identity-in effect, to the human spirit—of changing what are really just normal mental states?

Is a life without sadness or daydreams really a human life? Is a short nap not better than Provigil—or for that matter better than a latte? Do we really have to multi-task for a dozen hours on end? And, philosophically speaking, do we want these medical transformations of the human mind to pervade society in the future?

That is certainly one set of ethical philosophical questions, but there is another. It is the question that comes up when one person comes to a doctor and asks for help. You assess the situation and you are not sure you can really, truly call this person sick. But on the other hand they are in distress, and you have something that can help them.

Certainly, you don't want to be simple-minded about it. You want them to find out why they are sad or sleepy or forgetful and try tinkering with their lives before you tinker with their brains. But what if they've tried and it hasn't worked, or if the life changes are not possible? What do you do when you come to that crossroads?

In many cases, you will look up and see neither a green nor a red light but a slowly flashing yellow one. It is situation that calls not for blanket philosophies but individual judgment, and it is a crossroads that all of us, not just doctors, will increasingly arrive at in the decades to come.


  1. Clare says:

    From my experience there is also the catch that prescribing the right medications in the right amounts for conditions like ADHD, Tourettes or depression is as much an art as a science. Too little and there is no effect; too much and side effects may outweigh the benefits. Some patients find one drug works well for them; another patient may not consider there is noticeable improvement. And all the time, other variables are at work that can alter the clinical picture (in children, of course, there is development itself). In other words, there is no single moment at which a transformation is effected, but a continuing ebb and flow of reactions, adjustments, failures and restorations.

    Thus I am not convinced that the interventions you speak of can really smooth out all the heights and depths of human experience. And for all the people who may choose to make themselves taller or faster, there will be others who do not. Even people with chronic conditions (like asthma) sometimes back off from medications that do make a difference to their health simply because they get tired of having to rely upon them.

    I too am more bothered that so many are prevented by inadequate means from even the chance to try drug therapies that will help them than that they exist at all. And it doesn’t stop at drugs; what about the intensive, expensive and time-consuming behavioral therapies that parents of children with, for example, autism are urged to undertake? These too make a marked difference in patient outcomes. There is no doubt that the cultural value of perpetual self-improvement has propelled us into situations where there seems no limit to what can be demanded of us – both for ourselves, and for our loved ones. But how much more cruel it is to demand it, and give no hope or help to those who cannot afford it?

  2. I come here for answers, and you give me more questions? 🙂

    I find this issue particularly disturbing and I can’t quite say why. Maybe I envision the worst-case scenario: a world of haves and have-nots in which the only way to compete is to be on these drugs but (even worse) it turns out that long-term use of these drugs erodes health and/or humanity. It’s an ugly dystopian scenario I can’t imagine hasn’t been explored before.

    Anyway, good to see you blogging.

    (Just as long as it doesn’t get in the way of any future books or other articles. Blogging can be an end unto itself, and even a sort of public journal in which I have found it possible to cultivate new ideas — but it can also just be a big time suck that vents the impulse to express whatever is on your mind in a way that might have less impact than other channels of expression. cf. Ze Frank on Brain Crack, which could be used to argue the case either way:…71106.html )

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