This is the second of a two-part examination of the ethics of and attitudes toward cognitive enhancement. The first installment by Dr. Rouse, “Cognitive Enhancement in Education: The State of the Issue,” appeared in the Fall 2013 issue of Dignitas.
While ethical analysis of potentially dangerous dilemmas is a thought-provoking philosophical exercise, the need for public policy development is usually tied directly to their actual prevalence and their near-term effects on society. For this reason, many authors have focused on whether or not the use of pharmaceutical cognitive enhancers is really a clear and present danger to society, and, if so, what types of policies might be crafted to protect society from that danger. Those who see the use of cognitive-enhancing drugs as morally illicit or potentially physically dangerous call for extreme caution in the development and approval of these drugs for enhancement purposes.[1] Generally, even those who advocate the approval of these drugs for enhancement purposes recognize that their availability would need to be regulated. That said, there are those who, while notably rare, advocate for the free and unfettered public access to these medications.
The current legal reality in the U.S. is that these drugs are prohibited for the use of enhancement. Drugs like methylphenidate (Ritalin® is one example) are approved by the FDA only for the treatment of diagnosable disorders such as ADHD. However, a parallel reality exists: College students and other individuals are illegally seeking, obtaining, and using these drugs for reasons beyond their therapeutic use. A number of studies have been done to ascertain the extent of such off-label use; they are reviewed below. Clearly, there already exists a black market for these drugs. Several authors warn that simple prohibition would not only perpetuate the black market for these drugs, but would be impractical to implement and police in the first place.[2] For this reason, well-conceived public policy on this issue is a widely recognized need.
Since there is still much to learn about these cognitive-enhancing drugs,[3] and because they are currently only approved for the treatment of particular disorders, one suggested option is simply to implement educational initiatives that will inform the public about the risks of taking such medication for the purpose of enhancement.[4] Proponents of this approach opine that the off-label use of nootropic (mind enhancing) drugs is inevitable, and, as such, we should ensure that users have access to our most current and reliable information about their efficacy and risks. Cakic notes
that the widespread non-medical use of methylphenidate suggests that students will use nootropics regardless of their safety and legality. Perhaps the most that can be hoped for is to have a better understanding of the dangers of nootropics so that students will take this into consideration when deciding whether or not to use them.[5]
Schermer suggests making this type of information available to students around the time of exams and adds that the government should be responsible for publishing public service announcements that inform potential users of “the realistic effects and risks” of nootropic drugs.[6]
Conceding the inevitable off-label use of cognitive-enhancing drugs and calling for better information dissemination may be a useful place to start, but many authors are also thinking ahead to the day when these pharmaceuticals might become legally available to the healthy. A 2008 Nature article by Greely et al. has become a well-known essay advocating for the widespread use of cognitive enhancers. The article makes a multi-faceted call for evaluation of risks and benefits, research into safety and an “enforceable set of policies to protect individuals from coercion and minimize enhancement-related socioeconomic disparities.”[7] Yet, Greely et al. stop short of suggesting actual policies that might accomplish these goals.
On the other hand, enhancement proponents Bostrom and Sandberg suggest a complete overhaul in the way that enhancement drugs are developed, tested, and approved.[8] They recognize that the current medical framework for drug approval makes it difficult for pharmaceutical companies to develop and research drugs that could be used for enhancement. Their proposal is to create a different approval path for cognitive-enhancing drugs. Their rationale lies in the fact that there exist precedents in past governmental policy for a focus on enhancing and protecting cognition; these include the prohibition of the use of lead in paint and tap water, helmet laws, age restrictions on alcohol consumption, folic acid fortification of breakfast cereals, and compulsory education. As an extension, if all of these laws protect and enhance cognition, then developing safe and effective pharmaceutical enhancers is merely the next logical step.[9]
Among these discussions of the range of governmental involvement in regulating pharmacological cognitive enhancers, the most common recommendation is for additional research and analysis to assess the pervasiveness of off-label use of these drugs, to elucidate public and healthcare professionals’ attitudes toward the use of these drugs for enhancement, to evaluate their true utility in the healthy, and to uncover the gamut of side effects they may cause. For instance, in her 2012 paper, Jayne Lucke calls for more research exploring attitudes about cognitive enhancement, because many academic, popular media and policy discussions are based on questionable assumptions about public attitudes and how those attitudes will shape public behavior.[10] To date, there have been a number of studies that have begun this pursuit of information. These studies are summarized in the remainder of this review in order to create a snapshot of what we currently know about usage patterns and attitudes regarding cognitive enhancement.
The answer to the call for more information began about ten years ago when empirical studies assessing the prevalence of off-label use of prescription stimulant medications started to emerge. The bulk of these studies have focused on college campuses. College students often have access to these medications through classmates with prescriptions for ADHD medications and are a readily-available population to survey and interview. As a result there is a solid body of literature examining the illicit usage patterns of cognitive stimulants such as methylphenidate (Ritalin®) and mixed amphetamine salts (Adderall®) among this group of college students.
McCabe, Teter, and colleagues have published a number of studies conducted in major university settings providing large samples in the midwestern United States. These studies indicate that about 8% of student respondents report using these drugs without a prescription at least once in their lifetime, and about 5-6% report using them in college within the last year.[11] This research group also performed the only large, multi-site university study, involving over 10,000 students from 119 universities in the United States, and found similar results. The life-time use prevalence was about 7%, while the past-year use prevalence was about 4%.[12] DeSantis and colleagues also surveyed usage patterns at a large university in the southeastern United States and found that a much higher 34% of student respondents in their survey reported the illegal use of ADHD stimulants.[13] Other studies have been conducted at small-tomedium sized universities in the United States that report usage prevalence rates in the 15-16% range among the student respondents,[14] while one study reports usage rates as high as 36%.[15] Lastly, several additional studies have examined usage patterns in particular student sub-populations like social fraternities. DeSantis et al. found that 55% of fraternity members surveyed at a large southwestern university reported nonmedical use of ADHD stimulants.[16]
Most of the studies reported above went beyond simply calculating usage statistics. In addition, they asked survey respondents to report motives for off-label stimulant use and means of acquisition of the drugs. In almost every study, the largest percentage of illicit users cited academic motives for off-label use.[17] Specifically, the majority of students reported using prescription stimulants in order to increase concentration and alertness.[18] Other reasons for use included getting high, losing weight, increasing sociability, increased memory and reducing fatigue.[19] By and large, these studies reveal that users generally took these drugs orally, although some students inhaled the drugs intranasally,[20] and that the most common mode of acquisition of ADHD stimulants was via friends that either gave away or sold excess pills.[21] Finally, these studies have revealed that male gender, Caucasian race, membership in a social fraternity or sorority, Jewish religious affiliation, low academic achievement, easy access to the drug, and weekly party behavior were all factors associated with illicit prescription stimulant use.[22]
A number of other studies, also surveying college students, have focused on exploring attitudes about the use of cognitive-enhancing drugs rather than simply estimating usage statistics. Most of these studies relied on interview techniques rather than paper or web surveys. As a whole, this body of literature suggests that students tend to believe the use of drugs like Ritalin® and Adderall® are physically safe, morally acceptable, and stigma-free.[23] During extensive interviews with illicit stimulant users, DeSantis and Hane learned that students assume stimulant use is safe because it is prescribed to their friends. Moreover, these students believed that stimulant use was morally acceptable and physically safe if done in moderation, particularly when undertaken “for the right reasons,” i.e. performing better academically.[24] Forlini and Racine found that when questioned about the acceptability of using cognitive stimulants in an educational setting, students expressed a conviction that individuals should have the freedom to choose whether or not to use cognitive stimulants, yet highlighted the need for personal integrity in the use of stimulants for study purposes.[25] Interestingly, some of the students interviewed in Forlini and Racine’s study expressed a fear of eventual coercion. One student commented, “I think it has the potential to become one of those things that you say, ‘I don’t really want to, but I feel like I don’t have a choice.’”[26] In contrast, two other studies which examined attitudes of students related to cognitive enhancement in Germany and Australia yielded different results. Students in Germany had a favorable disposition about using cognitive enhancers if they were deemed safe, but most of the respondents indicated that they were unsure about issues of addiction and fairness and therefore abstained from using these drugs.[27] On the other hand, a small study involving Australian college students revealed a more negative disposition toward the use of cognitive enhancers. The majority of the students interviewed indicated that they found the use of these drugs unacceptable and advocated awareness campaigns and enhancer use monitoring in academic settings.[28]
While assessing attitudes about cognitive enhancers in the “user” pool is important, assessing attitudes about these drugs in the “provider” pool is equally so. Fewer studies have addressed this issue with reference to healthcare professionals, but those that have provide some useful pilot data to consider. Hotze and colleagues surveyed 1500 physicians across the United States about the use of medical interventions for the purpose of enhancement. Many different types of enhancements were included in the survey questions, but 58% of the physicians surveyed indicated that drugs that help students learn faster in school should be allowed. 15% of these physicians indicated that they would prescribe such a drug to “normal” individuals without reservation, and 50% indicated that they would prescribe these drugs with reservations. Therefore, 65% of the surveyed physicians indicated that they would prescribe cognitive enhancing drugs to normal students if legally available.[29] However, the majority of these physicians expressed disdain for drugs that would enhance physical fitness or increase aggression in soldiers, indicating that the end results of the mode of enhancement seem to matter to the provider. Cognitive enhancements such as increased memory and improved school performance were rated as more acceptable than any improvement in physical performance.[30] The authors of this study summarize the overall responses from physicians as showing “considerable ambivalence around the issue of enhancement.”[31]
Forlini and Racine also interviewed healthcare providers in their study. The healthcare providers expressed concerns over the health consequences of the use of cognitive enhancing drugs. The sum of their responses indicated that they believed cognitive enhancer use is an issue of personal choice, but would be concerned for the mental health of students who felt pressured enough to turn to pharmacological enhancers to get their work done. However, they concluded that cognitive enhancement is unacceptable and could not formulate any scenario where it would be acceptable.[32]
In response to these studies, Forlini and Racine analyzed potential causes and implications of healthcare professionals’ ambivalence on this issue. Their commentary suggests that the ambivalence identified by Hotze et al. may be a function of confusing semantics. Forlini and Racine take issue with the wording of multiple survey items in the Hotze et al. study and find “enhancement” a misleading and ambiguous term in this context. They suggest that using the phrase “nonmedical use of medicine for enhancement” would have been less ambiguous and may have led physicians to answer more decisively in either the positive or negative direction.[33] They also believe the physicians may have been inclined to generate positive attitudes toward enhancement goals that had short term clinical significance (like enhancing memory or helping students succeed), but would likely have been more hesitant regarding more “distal social goals” (like increasing factory worker productivity or increasing aggression in soldiers).[34] This commentary ends with an optimistic view of the ambivalence and ambiguity: fodder for additional consideration.
Lastly, getting a sense of the use statistics, awareness and attitudes of the more general public is admittedly more difficult than doing so for the previous two populations, and to date very few studies have embarked on such a mission. Kroutil and colleagues analyzed data from the 2004 National Survey on Drug Use and Health, specifically related to questions addressing the misuse of prescription ADHD stimulants. Past year off-label use of these drugs was most common in individuals between the ages of 18 and 25. However, that prevalence rate was only 1.3%. Only 0.1% of surveyed persons over 26 years old reported taking ADHD medications without a prescription. Whites and those in rural areas were more likely to have used cognitive enhancers than other groups.[35] A later study employed an internet survey involving over 4000 adults (18-49) in the United States and found that past year off-label stimulant use prevalence was about 2% overall and about 4% among participants that were 18-25 years old. Consistent with the college-based studies discussed above, most stimulant users report obtaining them from friends with prescriptions and state that productivity was their main motivation for off-label use.[36]
A couple of surveys have also focused on usage patterns and attitudes in the scientific community specifically. Two neuroscientists in the United Kingdom surveyed their colleagues and revealed that some of them have used the sleep-inhibitor modafinil (Provigil®) to combat the effects of jet lag.[37] Though their article is characterized by thought-provoking questions with few answers, it did prompt the editors of the journal Nature to conduct an internet poll of their readers. This poll received 1400 responses from individuals in six countries and revealed that roughly 20% of respondents had used drugs non-medically to enhance cognitive performance in some way. The most commonly used drug was methylphenidate and the most prevalent reason for use was to increase attention. Users procured these drugs primarily through prescription (it is unclear whether this includes diverted prescriptions) and the internet. Interestingly, 80% of respondents thought that healthy adults should be able to take these drugs for enhancement, and almost 70% claimed that they would risk mild side effects to take cognitive enhancing drugs. In contrast, 86% of the same population of respondents indicated that healthy children under 16 should not be allowed to take these drugs. About one-third of participants said that they might feel pressured to give cognitive enhancers to their children if their children’s peers were taking them.[38]
Whereas official government contribution to the discussion of cognitive enhancement in the United States is currently sparse, the UK Government Office for Science Foresight Mental Capital and Wellbeing Project addressed this topic. Four UK neuroscientists and psychologists wrote the project’s report calling for increased public education on the moderate effects and the risk of addiction and side effects of these drugs. The report is mostly informational regarding the mechanism of action of the drugs as well as a review of what is known about current usage rates, but the existence of this document highlights the importance of the discussion on a national level.[39]
It is clear that the last decade has ushered in much thought, discussion, and research on the use of cognitive enhancing drugs. Yet, there is much that we still do not know. Safety and efficacy are perhaps the primary questions, but answering those questions falls within the purview of medical science. Usage patterns and attitudes in the general public have not been fully examined, and the attitudes of medical professionals toward cognitive enhancement and their role in prescribing the drugs are still somewhat unclear. All of these areas merit further research.
In addition, while the general college population has been surveyed in several studies, little is known about the usage patterns and attitudes of particular sub-populations of students. The fact that usage seems to be much higher in fraternities and sororities than in the general college population indicates that a student’s community context plays a role in their attitudes about cognitive enhancement and their tendency to use enhancing drugs.
One particularly quiet voice in this discussion has been that of the Christian church. While a few Christian bioethicists and physicians such as C. Ben Mitchell and William Cheshire have commented on this subject, there is not a substantial body of literature that addresses the issue from a Christian perspective. Moreover, there are no studies that examine cognitive enhancer usage or attitudes toward use among Christian individuals specifically. One obvious venue in which to explore usage and attitudes among Christians would be that of explicitly Christian colleges. Surveys of Christian student populations would begin to elucidate whether there is any notable difference between usage and attitudes in Christian college students as compared to students at non-Christian colleges. Such data could help to spark an interesting and fruitful conversation about the relationship between the principles of the Christian faith and the issues surrounding pharmacological cognitive enhancement.
It is for precisely these reasons that I initiated a 2013 pilot study in partnership with CBHD to examine the attitudes and usage of cognitive enhancing drugs among Christian college students at several institutions. It is our hope that this will serve as the basis of further studies that can assist student development personnel in their work with students, as well as provide important data for additional consideration. Results of this preliminary study will be forthcoming within the next year.
[1] William Cheshire, “Grey Matters: Just Enhancement,” Ethics and Medicine: An International Journal of Bioethics 26, no. 1 (2010): 7-10.
[2] Nick Bostrom and Rebecca Roache, “Smart Policy: Cognitive Enhancement and the Public Interest,” in Enhancing Human Capacities, ed. Julian Savulescu, Ruud ter Meulen, and Gary Kahane (Oxford: Wiley-Blackwell, 2009), 6; Nick Bostrom and Anders Sandberg, “Cognitive Enhancement: Methods, Ethics, Regulatory Challenges,” Science and Engineering Ethics 15, no. 3 (2009): 331; Vince Cakic, “Smart Drugs for Cognitive Enhancement: Ethical and Pragmatic Considerations in the Era of Cosmetic Neurology,” Journal of Medical Ethics 35, no. 10 (2009): 613; Henry Greely et al., “Towards Responsible Use of Cognitive-Enhancing Drugs by the Healthy,” Nature 456, no. 7223 (2008): 704; Martha Farah et al., “Neurocognitive Enhancement: What Can We Do and What Should We Do?” Nature Reviews: Neuroscience 5, no. 5 (2004): 424; Jayne Lucke et al., “Academic Doping or Viagra for the Brain?” EMBO Reports 12, no. 3 (2011): 200; Simon Outram and Eric Racine, “Developing Public Health Approaches to Cognitive Enhancement: An Analysis of Current Reports,” Public Health Ethics 4, no. 1 (2011): 102; Marrtje Schermer et al., “The Future of Psychopharmacological Enhancements: Expectations and Policies,” Neuroethics 2, no. 2 (2009): 81.
[3] For instance, there is still a lack of clarity regarding the impact and efficacy of cognitive-enhancing drugs on healthy individuals. Cf. Dimitris Repantis et al., “Modafinil and Methylphenidate for Neuroenhancement in Healthy Individuals: A Systematic Review,” Pharmacological Research 62, no. 3 (2010): 187-206; M. Elizabeth Smith and Martha Farah, “Are Prescription Stimulants “Smart Pills”? The Epidemiology and Cognitive Neuroscience of Prescription Stimulant Use by Normal Healthy Individuals,” Psychological Bulletin 137, no. 5 (2011): 717-741; Scott Vrecko, “Just How Cognitive Is “Cognitive Enhancement”? On the Significance of Emotions in University Students’ Experiences with Study Drugs,” AJOB Neuroscience 4, no. 1 (2013): 4-12.
[4] Cakic, 614; Marrtje Schermer, “On the Argument that Enhancing Is ‘Cheating’,” Journal of Medical Ethics 34, no. 2 (2008): 85.
[5] Cakic, 614.
[6] Schermer et al., 84.
[7] Greely, 704.
[8] Bostrom and Sandberg, 331-332.
[9] Ibid.
[10] Jayne Lucke, “Empirical Research on Attitudes toward Cognitive Enhancement Is Essential to Inform Policy and Practice Guidelines,” AJOB Primary Research 3, no. 1 (2012): 58-60.
[11] Sean McCabe, Christian Teter, and Carol Boyd, “Medical Use, Illicit Use and Diversion of Prescription Stimulant Medication,” Journal of Psychoactive Drugs 38, no. 1 (2006): 43-56; Christian Teter et al., “Illicit Use of Specific Prescription Stimulants among College Students: Prevalence, Motives and Routes of Administration,” Pharmacotherapy 26, no.10 (2006): 1501-1510; Christian Teter et al., “Illicit Methylphenidate Use in an Undergraduate Student Sample: Prevalence and Risk Factors,” Pharmacotherapy 23, no. 5 (2003): 609-617; Christian Teter et al., “Prevalence and Motives for Illicit Use of Prescription Stimulants in an Undergraduate Student Sample,” Journal of American College Health 53, no. 6 (2005): 253-262.
[12] Sean McCabe et al., “Non-Medical Use of Prescription Stimulants among US College Students: Prevalence and Correlates from a National Survey,” Addiction 100, no. 1 (2005): 99-106.
[13] Alan DeSantis, Elizabeth Webb, and Seth Noar, “Illicit Use of Prescription ADHD Medications on a College Campus: A Multimethodological Approach,” Journal of American College Health 57, no. 3 (2008): 315-316.
[14] Quinton Babcock and Tom Byrne, “Student Perceptions of Methylphenidate Abuse at a Public Liberal Arts College,” College Health 49, no. 3 (2000): 143-144; Kristina Hall et al., “Illicit Use of Prescribed Stimulant Medication among College Students,” Journal of American College Health 53, no. 4 (2005): 167-169; Barbara White, Kathryn Becker-Blease, and Kathleen Grace-Bishop, “Stimulant Medication Use, Misuse, and Abuse in an Undergraduate and Graduate Student Sample,” Journal of American College Health 54, no. 5 (2006): 264.
[15] Kathryn Graff Low and A. E. Gendaszek, “Illicit Use of Psychostimulants among College Students: A Preliminary Study,” Psychology, Health and Medicine 7, no. 3 (2002): 285.
[16] Alan DeSantis, Seth Noar, and Elizabeth Webb, “Nonmedical ADHD Stimulant Use in Fraternities,” Journal of Studies on Alcohol and Drugs 70, no. 6 (2009): 953.
[17] Sean Barrett et al., “Characteristics of Methylphenidate Misuse in a University Student Sample,” Canadian Journal of Psychiatry 50, no. 8 (2005): 458-459; DeSantis, Noar, and Webb, “Nonmedical ADHD Stimulant Use in Fraternities,” 953; DeSantis, Webb, and Noar, 317-319; Hall et al., 170; Low and Gendaszek, 285; Teter et al., “Prevalence and Motives for Illicit Use,” 256; Teter et al., “Illicit Use of Specific Prescription Stimulants,” 1505; White, Becker-Blease, and Grace-Bishop, 264.
[18] Hall et al., 170; Teter et al., “Prevalence and Motives,” 256; Teter et al., “Illicit Use of Specific Prescription Stimulants,” 1505; White, Becker-Blease, and Grace-Bishop, 264.
[19] DeSantis, Webb, and Noar, 317-319; Teter et al., “Prevalence and Motives,” 256; Teter et al., “Illicit Use of Specific Prescription Stimulants,” 1505; White, Becker-Blasé, and Grace-Bishop, 264.
[20] Babcock and Byrne, 144; White, Becker-Blasé, and Grace-Bishop, 264; Teter et al., “Illicit Use of Specific Prescription Stimulants,” 1505-1506.
[21] Barrett et al., 458-459; DeSantis, Webb, and Noar, 320-321; DeSantis, Noar, and Webb, “Nonmedical ADHD Stimulant Use in Fraternities,” 953.
[22] McCabe et al., 98-99; McCabe, Teter, and Boyd, 50; Teter et al., “Prevalence and Motives for Illicit Use,” 256; Teter et al., “Illicit Methylphenidate Use,” 612; Teter et al., “Illicit Use of Specific Prescription Stimulants,” 1504.
[23] DeSantis, Webb, and Noar, 322; DeSantis, Noar, and Webb, “Nonmedical ADHD Stimulant Use in Fraternities,” 953; Alan DeSantis and Audrey Hane, “‘Adderall Is Definitely not a Drug’: Justifications for the Illegal Use of ADHD Stimulants,” Substance Use and Abuse 45 (2010): 35-41.
[24] DeSantis and Hane, 35-41.
[25] Cynthia Forlini and Eric Racine, “Autonomy and Coercion in Academic ‘Cognitive Enhancement’ Using Methylphenidate: Perspectives of Key Stakeholders,” Neuroethics 2, no. 3 (2009): 171.
[26] Forlini and Racine, 170.
[27] Andreas Franke et al., “Attitudes Toward Cognitive Enhancements in Users and Nonusers of Stimulants for Cognitive Enhancement: A Pilot Study,” AJOB Primary Research 3, no. 1 (2012): 50-51.
[28] Stephanie Bell et al., “Australian University Students’ Attitudes Towards the Acceptability and Regulation of Pharmaceuticals to Improve Academic Performance,” Neuroethics 6, no. 1 (2013): 197-205.
[29] Timothy Hotze et al. “‘Doctor, Would You Prescribe a Pill to Help Me…?’ A National Survey of Physicians on Using Medicine for Human Enhancement,” The American Journal of Bioethics 11, no. 1 (2011): 7.
[30] Ibid.
[31] Ibid, 8.
[32] Forlini and Racine, “Autonomy and Coercion,” 170.
[33] Ibid.
[34] Cynthia Forlini and Eric Racine, “Considering the Causes and Implications of Ambivalence in Using Medicine for Enhancement,” American Journal of Bioethics 11, no. 1 (2011): 16.
[35] Larry Kroutil et al., “Nonmedical Use of Prescription Stimulants in the United States,” Drug and Alcohol Dependence 84, no. 2 (2006): 137-140.
[36] Scott Novak et al., “The Nonmedical Use of Prescription ADHD Medications: Results from a National Internet Panel,” Substance Abuse Treatment, Prevention and Policy 2, no. 32 (2007): 7-9.
[37] Barbara Sahakian and Sharon Morein-Zamir, “Professor’s Little Helper,” Nature 450, no. 7173 (2007): 1158.
[38] Brandon Maher, “Poll Results: Look Who’s Doping,” Nature 452, no. 7188 (2008): 674-675.
[39] Sharon Morien-Zamir et al. “State-of-Science Review: SR -E9 Pharmacological Cognitive Enhancement.” Mental Capital and Wellbeing: Making the Most of Ourselves in the 21st Century (UK Government Office of Science, 2008), http://webarchive.nationalarchives.gov.uk/20130502130215/http://www.bis.gov.uk/assets/foresight/docs/mental-capital/sr-e9_mcw.pdf.
Susan Rouse, "Cognitive Enhancement in Education: A Literature Review,” Dignitas 21, no. 3 (2014): 1, 9–12.
