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Cognitive Enhancement

Cognitive Enhancement, Lifestyle Choice or Misuse
of Prescription Drugs?
Ethics Blind Spots in Current Debates
Eric Racine & Cynthia Forlini
Received: 16 July 2008 / Accepted: 31 July 2008
# Springer Science + Business Media B.V. 2008
Abstract The prospects of enhancing cognitive or
motor functions using neuroscience in otherwise
healthy individuals has attracted considerable attention
and interest in neuroethics (Farah et al., Nature
Reviews Neuroscience 5:421–425, 2004; Glannon
Journal of Medical Ethics 32:74–78, 2006). The use
of stimulants is one of the areas which has propelled
the discussion on the potential for neuroscience to
yield cognition-enhancing products. However, we
have found in our review of the literature that the
paradigms used to discuss the non-medical use of
stimulant drugs prescribed for attention deficit/hyperactivity
disorder (ADHD) vary considerably. In this
brief communication, we identify three common paradigms—
prescription drug abuse, cognitive enhancement,
and lifestyle use of pharmaceuticals—and
briefly highlight how divergences between paradigms
create important “ethics blind spots”.
Keywords Neuroethics . Enhancement .
Prescription drug misuse . Lifestyle drugs .
Public health
Background
The use of prescription pharmaceuticals for reasons
other than those medically intended, commonly called
“prescription drug abuse” represents a potentially
growing health problem. In the United States (US), 48
million individuals over the age of 12 have used1
prescription drugs non-medically ranging from central
nervous system (CNS) depressants and opioids to
stimulants [12]. The non-medical use of prescription
stimulants (e.g., methylphenidate) in particular has
been found to range from 5% to 35% in surveys of
North American young adult and adolescent populations
[18]. Rates for non-medical use of stimulants to
specifically improve academic performance range from
3% to 11% in college students (reviewed in Table 1).
Similar patterns of prescription use have recently been
reported in a Nature-sponsored survey where 20% (N=
288/1,427) of respondents reported having used drugs
non-medically to improve concentration, focus and
memory [11]. Methylphenidate was the most commonly
Neuroethics
DOI 10.1007/s12152-008-9023-7
E. Racine (*) : C. Forlini
Institut de recherches cliniques de Montréal,
Montreal, Canada
e-mail: Eric.Racine@ircm.qc.ca
E. Racine : C. Forlini
Université de Montréal,
Montreal, Canada
E. Racine
McGill University,
Montreal, Canada
1 In this DISSERTATION, we use the term “non-medical use” to: (1) reflect
the fact that the uses we refer to are not medically approved and
(2) take some distance from the prescription drug abuse and
cognitive enhancement paradigms that we are discussing.
used drug in that survey (62%; N=132/214). Potential
contributing factors to the spread of non-medical
prescription use include the low cost of prescription
drugs relative to illegal drugs, the availability of drugs
through several channels other than traditional prescription,
and the emergence of on-line pharmacies
[12]. Consequently, the non-medical use of pharmaceuticals
has created a source of growing medical and
ethical problems. Currently, various paradigms are
employed to approach non-medical prescription use
reflecting a wide range of views and ethical opinions.
The Prescription Drug Abuse Paradigm
Most public health studies on the nature and prevalence
of non-medical use of prescription stimulants
name the phenomenon “prescription drug abuse”.
This paradigm expresses concerns for the health of
individuals engaging in those practices and highlights
the health risks and potential for dependence associated
with the non-medical use of drugs like methylphenidate.
However this paradigm has a number of
important drawbacks such as applying the harsh
language of illicit drug abuse to pharmaceuticals
while some of the actors and contexts involved are
markedly different. For example, a black market does
exist for prescription drugs but students also resort to
feigning symptoms of attention deficit/hyperactivity
disorder (ADHD) in order to obtain methylphenidate
from doctors. Further, the strong stance against nonmedical
prescription use in the abuse paradigm may
not fully convey the ambivalence in the medical and
bioethics communities as well as in the general public
regarding the ethics of this practice. In fact, competing
paradigms (reviewed below) express some enthusiasm
for the beneficial effects of non-medical use of
pharmaceuticals [2, 3].
The Cognitive Enhancement Paradigm
In the bioethics literature the term “prescription drug
abuse” is rarely encountered and much of the
discussion surrounding the non-medical use of pharmaceuticals
is based on descriptions of the phenomenon
as “cognitive enhancement” or “performance
enhancement” (e.g., President’s Council on Bioethics
in the US; discussion DISSERTATION of the British Medical
Table 1 Brief review of studies reporting prevalence rates of lifetime non-medical prescription stimulant (NMPS) use and NMPS use specifically for cognitive enhancement (CE)
in college student populations
Study Sample population NMPS use (%) NMPS use for CE (%)a
Teter et al. Pharmacotherapy. 2006 [17] 4,580 college students in a large Midwestern university 8.3 5.4 (enhance concentration) 5.0 (enhance studying)
4.0 (enhance alertness)
Prudhomme White et al. J Am Coll
Health. 2006 [15]
1 025 students at the University of New Hampshire 16.2 11.0 (enhance concentration) 8.7 (enhance studying)
3.2 (enhance grades)
Teter et al. J Am Coll Health. 2005 [16] 9161 undergraduate students at the University
of Michigan
8.1 4.3 (enhance concentration) 3.2. (enhance alertness)
Hall et al. J Am Coll Health. 2005 [7] 381 college students from the University of Wisconsin-Eau
Claire
13.7 3.7 (enhance studying)
Graff Low and Gendaszek, Psychol
Health Med. 2002 [10]
150 undergraduate students at a small, competitive
college in the US
35.3 8.2 (enhance intellectual performance) 7.8
(enhance studying)
a Our own calculation based on data presented in the studies
E. Racine
Association [2, 14]). In contrast to the first paradigm,
this one incorporates the potential benefits of increasing
cognitive function beyond ordinary or average
capacities [1]. Because of this focus, the enhancement
paradigm has highlighted the potential impact on the
individual per se addressing issues related to identity
and personhood (are we the same with or without
performance-enhancement drugs), autonomy (will we
be coerced into abusing prescription drugs to compete
with others if enhancement practices become widespread),
and the meaning of medicine (is it within the
purview of medicine to enhance and not only treat).
However, from a medical and scientific perspective,
describing the phenomenon as “enhancement” does
not resonate with the unknown risks of long term nonmedical
use of prescription drugs. Accordingly, this
paradigm has generated many polarized debates
framed as “to enhance or not to enhance” while
paying less attention to the conditions under which
enhancement of function could become ethically
acceptable (e.g., obtaining evidence about long-term
side-effects; assessing risks of dependence). Strikingly,
the interdisciplinary bioethics community is not in
tune with the more critical public health perspectives
and this perhaps partly reflects why some enthusiastic
portrayals of non-medical prescription drug use are
encountered in the bioethics literature.
The Lifestyle Use of Pharmaceuticals Paradigm
Finally, the “lifestyle” paradigm constitutes a third
and less technical paradigm employed occasionally in
the scientific literature but with greater emphasis in
the public domain. The description of the non-medical
use of prescription drugs as a “lifestyle choice”
transforms “prescription drugs” into “lifestyle drugs”.
The lifestyle paradigm expresses the optimistic belief
that pharmaceuticals can not only help individuals
face illness but help them “be all that they can be”
based on their own decisions and goals. Instances of
this paradigm are found in the media where the nonmedical
use of stimulants like methylphenidate, for
example, are designated as “better living through
chemistry” [19] and methylphenidate dubbed a “study
aid” [13], a “brain steroid” [5], and a “smart drug” [5,
13]. This paradigm thus expresses lay understandings
of non-medical use of drugs and illustrates the current
ambivalence regarding the medical and ethical nature
of this practice. This is reflected in the provocative
comparison of Ritalin to, “study tools, just like tutors
and caffeine pills” [8]. The lifestyle paradigm suggests
that the emerging non-medical uses of pharmaceuticals
reflect an individual choice of citizens living
in liberal democratic societies marked by medical
consumerism. Accordingly, it is no longer necessary
to “frequent the dark corners of campuses to come
across a student drug that is fast growing in
popularity” [13]. Though the lifestyle paradigm
expresses the social acceptance that non-medical drug
use is gaining outside the medical community,
referring to pharmaceuticals using metaphors like
“miracle drug” [9] in the media is likely to convey
inappropriately that non-medical prescription use is a
safe and acceptable practice in spite of unknown
risks. Hence, this paradigm is perhaps the most
challenging for the medical and ethics communities
because its view of the role of pharmaceuticals for
self-achievement deviates from the common understanding
of pharmaceuticals as treatment prescribed
for illness.
Divergence between Paradigms Create Ethics
Blind Spots
The existence of distinct paradigms for approaching the
non-medical use of pharmaceuticals clearly shows the
lack of consensus on the acceptability of the practice.
However, paying attention to diverging paradigms can
help identify some important “ethics blind spots”. On
the one hand, favorably describing non-medical prescription
use as “enhancement” and the use of methylphenidate
as a “study aid” or a “lifestyle choice” may
lead to the unintended dissemination of non-medically
approved practices based on misinterpretations. The
media in particular has adopted sensationalist language
to describe the lifestyle impact of non-medical prescription
use while bioethics scholarship has already heavily
and optimistically labeled the practice “enhancement”
without clear scientific evidence and knowledge of
long-term risks. On the other hand, the lack of
acknowledgment of growing public enthusiasm for
non-medical prescription use could lead public health
interventions astray. This is likely to happen if such
interventions are based solely upon the prescription drug
abuse paradigm and neglect the social acceptance of
non-medical prescription use found in the enhance-
Cognitive enhancement, lifestyle choice or misuse of drugs?
ment and lifestyle paradigms. Indeed, what may be
viewed as problematic from a public health perspective
(i.e., viewed as prescription abuse) may
have already started becoming legitimate in the
public domain (i.e., viewed as “cognitive enhancement”
or a lifestyle choice). To better understand
the ethics of performance-enhancement drugs at a
social level, further research will be needed to
determine which paradigm or which combination of
paradigms reflects the views of stakeholders such
as students, lay citizens, healthcare professionals,
and public health authorities.
Acknowledgments We would like to acknowledge the
support of the International Institute for Research in Ethics
and Biomedicine, the Canadian Institutes of Health Research,
the Social Sciences and Humanities Research Council of
Canada, and the Institut de recherches cliniques de Montréal.
Thanks to Nicole Palmour, Dr. Emily Bell, and Dr. David
Bouvier. The authors report no conflicts of interest
References
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E. Racine
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