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Pill Power

Publication Date: 
September 28, 2009
Discover Presents The Brain
Amy Barth

Professor Hank Greely, an expert in law and biosciences, discusses the legal, social, and ethical issues of cognitive enhancers with Amy Barth of Discover magazine:

If you could pop a pill that would make you smarter and more productive, would you do it? Millions of people already have, it seems. Surveys show that healthy kids and adults throughout the United States use prescription drugs like Adderall and Ritalin to improve grades and boost productivity. An online poll recently conducted by the journal Nature reported that 20 percent of more than 1,400 respondents used prescription drugs for a cognitive boost. Nearly half of those said they took the pills daily or weekly.

That is not such a bad thing, says Stanford Law School professor Hank Greely. He began investigating the legal, social, and ethical issues of bioscience more than 15 years ago and is now director of the program in neuro-ethics at the Stanford Center for Biomedical Ethics. He argues that as long as cognitive enhancers are safe and effective, there should not be a broad prohibition against them.

SOME PEOPLE say that using cognitive enhancers is cheating, but you disagree. Why?

It's only cheating if it's against the rules. And since the question is "What should the rules be?" saying it's cheating doesn't help very much. Is it cheating to use a computer to take notes? The old Greek bards who memorized The Odyssey were probably quite upset when handwriting came along. If there are laws or rules out there that these drugs violate, then that's cheating. But we're deciding what the laws or rules should be, and there needs to be some convincing reason why it's cheating.

People also argue that taking these drugs is unnatural, but so much of what we do is unnatural. In a state of nature, we wouldn't be wearing the clothes we are wearing. We might be wearing skins, but not cotton or eyeglasses. We wouldn't be using computers. If you want to make an argument about naturalness, there needs to be a convincing reason why our current level of unnaturalness is OK.

SO YOU believe that cognition-enhancing drugs are acceptable. Do you also think they are beneficial?

If they work well and they're safe, people will be able to use their brains more effectively. It's like how a computer allows me to use my brain more effectively. It allows us to be more effective in our own lives and to improve the world. This may be a prejudice of smart people, but smart people tend to think a world with smarter people will be a better world. I don't know whether the empirical evidence points that way, but I'm not sure it doesn't.

WHAT KIND of smart drugs are available now, and what is on the horizon?

The biggest class of drugs with this potential are memory drugs. Right now the ones we've got—Adderall, Ritalin, Provigil—are stimulants. They keep you awake and alert and maybe improve focus. Pharmaceutical companies are spending billions of dollars trying to come up with drugs to help people with early stages of dementia or even with age-appropriate memory impairment. If those work, and if they work on younger people, then we'll see those in places like organic chemistry finals.

ISN'T ENDORSING cognitive enhancers a lot like supporting the use of steroids in sports?

It's kind of like that, but unlike sports, cognitive enhancement could have some positive spin-offs. It doesn't matter very much whether a person who wins the Olympic weight-lifting gold medal is Turkish or Bulgarian, or whether the record is 300 kilograms or 302 kilograms. But let's say cognitive enhancing drugs improve the ability of bioscientists to come up with a disease treatment. That matters, and it has positive spin-offs.

WHAT ABOUT the moral perspective--do you think taking smart drugs is as ethical as hiring a private tutor?

Yes. They're just as ethical, and also just as ethically questionable. SAT prep has some ethical issues in terms of the socioeconomic discrimination implicit in expensive tutors. We should be thinking about those fairness issues. Similarly, we'll have to figure out fairness issues of enhancing drugs. My basic take on all of this is that most of the discussion on both sides is too simplistic. It depends on safety, efficacy, and how the drugs work—not just how well they work. To say that "this is always bad" or "this is always good" is foolish.

AS MORE effective cognitive enhancers come on the market, how does the legal system need to adapt?

Most drugs get out there when the Food and Drug Administration approves them for treatment of a disease. But once a drug is approved for one thing, doctors can legally prescribe it for anything else. Drugmakers only need to show safety and efficacy for one kind of use. I think we should require proof of safety and efficacy in healthy people—not just people with disease—for drugs we think will have a significant enhancement market. It would probably take a legislative change, but it would be a good one.

Also, various parts of society will have to make decisions on their own about whether enhancers are fair. An overall federal law isn't right because circumstances differ from place to place. Should graduate schools allow students to use memory pills? Should the bar exam allow them? The drugs we've got right now aren't effective enough or dangerous enough to make those issues overwhelmingly powerful. If people start using enhancing drugs that are a lot more effective or a lot more dangerous, schools will have to deal with it.

HAVE YOU yourself ever taken cognition-enhancing drugs?

I use caffeine regularly. I have never used any of the ADD/ADHD drugs such as Ritalin. I have, three times, used modafinil to stay awake after a red-eye flight from San Francisco to D.C. I might use it again for that purpose. If there were a safe and effective drug for improving memory, I would be very tempted to take that. It's not clear whether it would count as "enhancing," as my memory has suffered normal—I hope—attrition as I've aged. I'd like to have back the very good memory I now think I had in my twenties and thirties.

WHAT ARE some of the other important emerging ethical issues in neuroscience?

Let's say you round up 20 of the usual subjects—undergrad psych students—for a functional magnetic resonance imaging experiment. You stick them in a scanner, have them listen to music, and see what happens to their brains. For some disconcertingly large number of those apparently healthy undergraduates, you see something weird in their brain. It happens—you see something odd anywhere from 15 to 30 percent of the time. Do you tell them? Do you send them to a neurologist? If you send them to a neurologist, who pays for it? Consent forms need to address this.

Other questions relate to free will and responsibility. I think within the next 10 to 20 years we're going to be able to predict a significant number of serious neurological and mental diseases. If a brain abnormality makes some people powerfully predisposed to violence, how responsible should we hold them for their actions?

THAT SUGGESTS a broader ethical question: Are we legally responsible for our actions if our brains make us act the way we do?

Some philosophers and neuroscientists think neuroscience will basically make the criminal justice system disappear. They think it'll convince us that we have no free will—and that if we have no free will, why should we punish people if they can't help themselves? I don't believe that. Whatever neuroscientists conclude, they'll never convince most of us that we don't have free will. Besides, the criminal justice system is about a lot more than just punishing people for moral failings. We try to deter people. We put them in prisons so they can't hurt other people. And we try—at least we used to try—to rehabilitate them. All those functions of the criminal justice system will survive.