Where Is Line Between Therapy, Enhancement?

Rosenthal argued, however, that the moral aspects of cognitive and other enhancements for healthy people are far from black and white. The line between enhancement and therapy is not always clear cut, because the differences of health, subclinical disease, and disease are not absolutely distinct.

Rosenthal pointed out that efforts to improve human limits have always been a part of the human condition. Nonmedical means of cognitive enhancement are generally accepted as perfectly ethical. “Why is psychotherapy or tutoring acceptable, but not medications?” he asked.

Taking prescription drugs to enhance mental abilities still makes many people within and outside of medicine uneasy, yet many medical interventions intended to reverse the effects of aging and improving the quality of life, such as drugs for treating erectile dysfunction and cosmetic procedures, have been accepted by society. Rosenthal questioned whether there are any real differences between these types of enhancements. For example, caffeine is a legal substance that enhances attention and cognitive function. In other words, drinking coffee may not be fundamentally different from taking modafinil to do better work.

At the center of the argument against artificial enhancements to natural health is a “tension between the competitive reality and social contract,” Rosenthal said. Such enhancements may give people who can afford them an “unfair advantage” that may be inconsistent with the concept of fairness and equality. On the other hand, inequality permeates all aspects of society. People are not born with the same abilities and deficits. Rosenthal noted that, in reality, difference in socioeconomic status already causes inequalities in, for example, nutrition and education, which lead to inequality in mental development.

Another argument against enhancements is the possibility of direct or indirect coercion with the widening availability and use of “cosmetic psychopharmacology.” For example, should pilots be required to take cholinesterase inhibitors to fly safer? Will parents feel compelled to give medications to their children in order to “keep up” with other children's school performance?

There are voices in favor of not only permitting but also researching and developing these mind-enhancing technologies. A group of prominent researchers expressed their support for “responsible use of cognitive-enhancing drugs for the healthy” in a commentary published in Nature online on December 7, 2008.

These authors believe that the use of cognitive-enhancing drugs not only should be allowed but should be actively developed and made available to the public through research of their benefits and risks. “The drugs ... along with brain stimulation and prosthetic brain chips, should be viewed in the same general category as education, good health habits, and information technology,” they wrote. The authors acknowledged that some of these drugs may be abused, but pointed out that regulating rather than prohibiting substances with abuse potential is nothing new.

Among the authors of the commentary were Barbara Sahakian, a professor of clinical neuropsychology at the University of Cambridge School of Clinical Medicine in the United Kingdom; Ronald Kessler, Ph.D., a professor of health care policy at Harvard Medical School; Michael Gazzaniga, Ph.D., a professor of psychology and director of the SAGE Center for the Study of Mind at the University of California, Santa Barbara, and a member on the President's Council on Bioethics; and Martha Farah, Ph.D., a Walter H. Annenberg Professor of Natural Sciences and director of the Center for Cognitive Neuroscience at the University of Pennsylvania.

Weighing the relative risks and benefits of a new drug or technology is a paradigm central to medical research, and this paradigm can be used to consider cognitive and other enhancements for healthy people as well, Rosenthal suggested. The difficulty, however, is that enhancements have barely been studied in clinical research, leaving physicians and psychiatrists with little or no evidence to make a judgment on particular questions, he said.

Reality is not waiting for psychiatry, bioethicists, and politicians to sort out the ethical complexities and come to a consensus on public policies, however. “Society hasn't laid out the rules, it's a big mess,” said Rosenthal. People are doing what they feel compelled to do. The number of people using these mind-enhancing drugs for nonmedical purposes will continue to grow, both Rosenthal and the Nature commentators believe. The trend seems inevitable.

“What enhancements have we been able to successfully avoid?” Rosenthal's question brought a room of laughter.

Perhaps the real question is how science and medicine will steer policies toward more rational and equitable use of enhancements for social good rather than banning them. ▪