This is the first of a two-part examination of the ethics of and attitudes toward cognitive enhancement. The first installment by Dr. Rouse, “Cognitive Enhancement in Education: A Literature Review," appeared in the Fall 2014 issue of Dignitas.
It is in our nature as humans to want to improve ourselves. We strive, both individually and corporately, to know more and accomplish more than those who came before us. Perhaps the most notable of such attempts to better ourselves is the eff ort we invest in pursuing knowledge through education. Education is so important to our culture that every state funds public education through high school. Clearly, we value the pursuit of knowledge in an eff ort to enhance our intellect.
What we value, we often want to improve. For this reason, the pursuit of intellectual or cognitive enhancement is not a new concept; indeed, the entirety of the teaching profession is aimed at the cognitive improvement of students. But we do not stop with cognitive enhancement via education. The cultural importance of maximizing cognitive skill and ability has also led us to medicalize intelligence, such that those with lower intelligence or substandard cognitive skills are diagnosed with medical conditions calling for medical intervention. So, pharmacological agents have been developed to bring those with cognitive performance classified as “dysfunctional” within the “normal” range. Drugs like methylphenidate (Ritalin© being the most recognized brand name) help those with attention deficits regain focus; modafinal (Provigil©) stabilizes wakefulness and vigilance in those who suffer from narcolepsy; and rivastigmine (Exelon©) slows memory loss in those suffering from dementia. However, as a consequence of the mechanism of action of these drugs and the wide range of functionality among individuals, these drugs can augment cognition even in individuals who do not meet the diagnostic requirements for a particular disorder. Therefore, the possible means for cognitive enhancement have moved beyond merely education and training into the realm of pharmaceuticals.
The response to this burgeoning frontier in cognitive enhancement has been mixed. Some view pharmacological cognitive enhancement as a new opportunity to raise the average in human achievement, while others fear that this is the first step down a slippery slope that ends in the degradation of human nature and human dignity. Still others question whether the use of such drugs for enhancement outside of therapeutics is even happening enough for us to bother addressing it, either ethically or practically, through public policy. In this essay, we will explore some of the distinctively ethical issues that arise in connection with cognitive enhancing drugs (viz. assessment of safety, justice/fairness, and concerns related to human nature and dignity). Then, in a future issue of Dignitas, we will return to this topic to explore some important empirical data and its implications for public policy.
Much of the ethical discussion and empirical research surrounding the issue of cognitive enhancement has focused on cognitive enhancement in college students; of the cognitive enhancing drugs available on the prescription market, those most accessible to college students are attention-enhancing drugs such as methylphenidate and mixed amphetamine salts. Therefore, for our purposes here we will focus on this student population and these drugs.
Leon Kass and the President’s Council on Bioethics, in analyzing the goals and ethics of human enhancement, acknowledge that “it is not difficult to appreciate, at least at first glance, the attractiveness of the goods being contemplated.”[1] Performing at our best, serving one another, and improving our world through quality work in our careers and the development of new technologies are all worthy pursuits. Yet the worth of a goal is not determined exclusively by the end-product of its fulfillment. This point emerges as the thesis of the PCOB’s treatise on human enhancement: The human experience is more about the sum of process and relationship than about their outcome.[2] This perspective highlights the emerging ethical dilemmas inherent in pharmacological cognitive enhancement. How does using drugs to enhance our human executive function, which oversees other cognitive processes such as attention and memory, affect our personal and social development? And, at a broader and more philosophical level, what implications might it have for what it means to live as a human person?
While opinions vary widely regarding most of the ethical issues that arise in connection with pharmacological cognitive enhancement, one concern reflected nearly universally in the literature is safety. All seem to agree that, first and foremost, drugs that are marketed for any reason, whether therapy or enhancement, should have a positive benefits-to-risk ratio.[3] This is particularly true for a drug that is taken electively, for a reason other than therapeutics. Risk/benefit analysis is difficult in such cases, because the definitions of acceptable risks and reasonable benefits become murky. For example, when risk/benefit analysis is conducted for a drug prescribed in the context of an illness or disorder, the benefits are couched in terms of relieving symptoms, normalizing function, and reducing morbidity. In the case of drugs used for enhancement beyond normal function (those that do not actually reduce morbidity in any significant way), what should be deemed an acceptable level of augmentation of function?[4] Moreover, if risks are defined as deleterious or unpleasant side effects that might be viewed as less deleterious than the untreated symptoms of the disorder, should any side effect or potential health risk engendered by pharmacological cognitive enhancers be acceptable for someone already capable of normal cognition, since such side effects could endanger her or his current “good” health?[5]
Perhaps a good starting place for a risk/ benefit analysis of a nootropic (mind enhancing) drug is evaluation of claims that the drug can offer true enhancement of mental or cognitive functions. In the case of methylphenidate, empirical and anecdotal evidence suggests that the enhancement potential is real, but not consistent across individuals or cognitive tasks. Outram[6] reviews a number of studies that provide evidence for cognitive stimulants’ improving working memory and executive function on novel tasks in normal adults. However, these studies also indicate that methylphenidate and related stimulants have little effect on concentration and attention in healthy subjects. Moreover, they provide evidence for a drug-induced impairment of previously learned tasks.[7] Anecdotally, on the other hand, college students who have taken methylphenidate without a prescription report that it helped them be attentive, stay awake, retain information and resist distraction during studying.[8] These students also report that methylphenidate has other positive, unintended side effects, like promoting weight loss and increased sociability.[9]
In light of their potential benefits, the risks of cognitive stimulants merit careful consideration. Methylphenidate and amphetamines function to increase attention by enhancing dopamine release in the brain. This effect is not selective, and while increasing dopamine in the prefrontal cortex augments attention, increasing dopamine in the reward pathway (mesolimbic dopamine pathway) results in euphoria. For this reason, methylphenidate, like any psychoactive drug that enhances dopamine in the mesolimbic dopamine pathway, is potentially addictive.[10] Additionally, methylphenidate and related drugs have been shown to reduce appetite[11] and cause sleep disturbances, and may also augment mental illness and be related to cardiovascular problems.[12] Moreover, many ethicists have expressed concern over broader, long-term changes in cognition that could result from the regular use of these drugs. Changes in cognitive style and long-term retention of information, premature cognitive decline, and inability to forget painful or irrelevant information are all potential side effects of these drugs.[13]
The unequivocal conclusion from the “safety” discussion has been a call for further research and policy safeguards related to pharmacological cognitive enhancers. Even Greely, an outspoken proponent of cognitive enhancement, advocates focused research to elucidate both the efficacy of these drugs and their potential negative side effects.[14] Moreover, Schermer et al. call for consideration of the impact of medicalization on our risk/benefit analysis of cognitive enhancing drugs.[15] They argue that the medicalization of cognitive ability has created a situation in which more and more people will perceive a “need” for cognitive stimulants, thus, potentially impairing their ability to make informed and rational decisions about whether the risks associated with the drugs are worth taking. As a result, the responsibility for individual risk/benefit assessment lies with the prescribing physician.[16] Bostrom and Roache echo this observation and add that the current “disease-focused model” is inadequate for addressing safety in the context of enhancement.[17] These authors all recognize that an acceptable benefit/risk assessment for a drug used as therapy may be deemed unacceptable when applied to a drug used for enhancement.[18] For this reason, Bostrom and Roache call for a new set of policy guidelines and approval processes for pharmaceutical companies to follow when seeking to market a drug for enhancement.[19]
The safety issue and related call for more research on the enhancement efficacy of nootropic drugs may be a moot point if society agrees that the use of cognitive enhancers is simply not fair. The fairness discussion surrounding cognitive enhancement focuses on whether or not such drugs confer an unfair advantage on those who use them. Assessment along these lines has been useful in evaluating the appropriateness of performance-enhancing drugs in sports. Clearly, athletes who use performance-enhancing drugs have a competitive advantage over those who do not. This is significant because competition is the basis of sport. There is a winner and there is a loser, and performance-enhancing drugs increase one’s chance of becoming the winner. Bostrom and Sandberg call this type of advantage a positional good.[20] The value of a positional good lies in the fact that others do not have it. While it is clear that performance-enhancing drug use in sports is a positional good, whether or not cognitive-enhancing drug use yields positional goods is hotly debated. Bostrom and Sandberg argue that cognitive abilities are not simple positional goods because they are intrinsically desirable.[21] Goodman offers a similar argument by assessing the benefits of cognitive performance as a non-zero sum activity. As opposed to zero-sum activities that have a clear winner and a clear loser, non-zero sum activities do not have a fixed number of winners and losers. Goodman, like Bostrom and Sandberg, argues that enhancement constitutes cheating only when a binding set of rules exists that aims to provide equal opportunity for winning to all participants.[22] However, cognitive performance and education, he argues, seldom fall within these parameters. Therefore, if cognitive enhancers are used to give an individual an advantage in, say, a competitive exam or a class graded on a curve, then one could consider their use cheating in that situation. But if pursuit of education and cognitive improvement is something that individuals do simply to improve themselves, then it is not a mere positional good, but a non-zero sum activity in which all individuals who cognitively enhance could benefit.[23] Therefore, according to this argument, using pharmacological cognitive enhancements is not cheating, or at least not always.
Moreover, many argue that viewing the use of cognitive-enhancing drugs in education as a form of cheating implies that educational opportunities are equal in the absence of pharmacological cognitive enhancement. In reality, a multitude of unequally distributed educational advantage opportunities exist. Access to good nutrition, tutoring, computer technology and other resources give some students, but not all, educational advantages every day.[24] Nevertheless, Cakic expresses concern that the use of cognitive enhancing drugs in education serves to make an already uneven playing field even more uneven, favoring the wealthy who have the resources to procure such drugs.[25] For Cakic, this serves only as a cautionary note and is not a strong enough concern to motivate prohibition.
However, the issue of fairness takes on another dimension when we consider the impact of cognitive enhancement on the whole of society as opposed to an individual or small groups of individuals. If the use of cognitive enhancers in education confers even a non-zero sum advantage, then individuals may come to interpret this advantage as necessary for success. On a social level, widespread use of cognitive enhancers could raise the “average” cognitive ability in a particular population. The danger in this scenario would be that individuals in that population may feel pressured or coerced into using cognitive enhancing drugs in order to “measure up.” Cakic discusses the “Red Queen principle” in which “an individual must continue developing in order to maintain their fitness relative to others with whom they are competing.”[26] The Red Queen principle as it relates to cognitive enhancement implies that if drugs such as methylphenidate substantially increase productivity, then individuals may feel pressured to use these drugs to “keep up” with their enhanced colleagues. Farah et al. envision a scenario where explicit coercion forces those who do not want to use cognitive enhancing drugs to do so anyway to keep their jobs or stay in school.[27] Greeley et al. acknowledge this possibility and seem to echo this concern, except in situations where the individual’s performance impacts the health and well-being of others. For example, they seem to advocate universal use of cognitive enhancers for military and medical personnel.[28] Yet, respect for autonomy seems to tip the balance in this analysis toward a disdain for coercion, even if that coercion is implicit. Farah recognizes that “[c]learly coercion is not a good thing.”[29] Yet, she goes on to assert that “it would seem at least as much of an infringement on personal freedom to restrict access to safe enhancements for the sake of avoiding indirect coercion of individuals who do not wish to partake.”[30] The same regard for fairness that leads us to disapprove of coercion evokes our desire for equal access. Of course one could make the same argument for education as well. If we would not restrict access to education because it creates an environment in which there is pressure to be educated, on what basis should we differentiate this situation from that of pharmacological cognitive enhancement?
So, in addition to worrying that those who do not want to partake in pharmaceutical cognitive enhancement might feel pressured to do so, some fear that individuals who do want to use cognitive enhancers will not have access to them. Discussions related to this aspect of fairness center around the almost certain notion that if drugs like methylphenidate were to become legalized for use in cognitive enhancement, they would be expensive and would likely not be covered by medical insurance. For this reason, a concern arises that only the wealthy would have access to these drugs, thus allowing the already troubling gap between the well-educated rich and the less-educated poor to become yet wider.[31] Moreover, it is unlikely that the drugs would ever be offered over-the-counter, so access would be restricted to those with the “high social capital and good information” to communicate effectively with a prescribing physician.[32] Overall, this perpetuates the success of those who know how to self-advocate and can afford the drugs and the detriment of those who lack such hallmarks of privilege.
Bostrom and Sandberg, however, make the point that the mere availability of cognitive enhancers could potentially begin to close the gap between the cognitively gifted and the cognitively disadvantaged. They point out that studies support the notion that drugs like methylphenidate have a more pronounced effect on those at the low end of the cognitive ability spectrum.[33] As a result, they call for a more nuanced analysis of the distribution issue, as they see equal distribution of cognitive enhancing drugs as analogous to access to public libraries and free education. Greeley likewise quips that “[o]ne could mitigate . . . inequality by giving every exam-taker free access to cognitive enhancements, as some schools provide computers during exam week to all students. This would help level the playing field.”[34] But proposed solutions calling for monitored, equal distribution of such drugs to entire student bodies are widely regarded as unrealistic, and so are not the focus of most ethical analysis of the subject.[35]
Once again, though, some writers who acknowledge the potential for distributive injustice characterize it as an inevitable fact of life, pointing out that inequality is already a pervasive element of education. Unequal access to expensive, high-quality schools, computer technology, tutoring services, good nutrition, etc. currently contributes to an undeniable “opportunity gap” in education. As a result, some authors conclude that while this scenario is not ideal, it has never been sufficient grounds for prohibiting access to a resource.[36]
The way in which these different ethical dimensions weave together is important to recognize. If cognitive enhancing drugs are not safe or do not offer sufficient cognitive improvement to offset their risks (if any level of benefit is capable of doing so at all), then objecting to unequal distribution would be, in Leon Kass’s estimation, like exclaiming, “The food is contaminated, but why are my portions so small?”[37] However, the safety issue also points to another perspective on the issue of distributive justice. Currently, we do not fully understand the range of side effects and long-term effects that drugs like methylphenidate have on individuals with normal cognitive function; the only way to assess the safety of these drugs is through research. But pharmaceutical research that would elucidate any negative effects of these drugs requires three things: Medical resources, money, and human subjects. Each of these raises issues of justice. William Cheshire and Ben Mitchell both argue that if drugs like methylphenidate became widely available for enhancement purposes, valuable medical resources such as physician and nurse time, drug availability, and testing to monitor side effects would be diverted from the truly sick.[38] Is it ethical to divert research dollars that could be invested in curing disease to the investigation of side effects of cognitive enhancers? Schermer et al. note that “it is not clear at all that investing money, time and expertise in developing cognitive enhancers would make more people better off.”[39] Additionally, concerns arise as to which population of individuals would likely be the subjects of such research. It is reasonable to imagine that the poor or cognitively disadvantaged might become likely candidates. Scenarios like this are uncomfortably similar to unjust human research studies of the past, such as the Tuskegee syphilis experiments, against the recurrence of which society is morally responsible to guard.
So, the wheel of ethical analysis continues to spin. However, means-oriented questions of safety, fairness and distributive justice are all issues that can be addressed and even potentially resolved if our society agrees that pharmacological cognitive enhancement is a good idea in the first place—a goal worthy of our pursuit. This consideration points to perhaps the deepest of all of the ethical questions surrounding cognitive enhancement: how this practice would affect human dignity and human nature.
The central ethical question regarding the use of cognitive enhancers relates to the underlying goal of enhancement, the betterment of human life. To evaluate if such drugs will indeed “enhance” our lives, we must first explore “what conception of a good life is behind the claims that radical enhancements would make human life better.”[40] What is good about human life, and how does pharmacological cognitive enhancement contribute to that? The pursuit of the good life is inextricably linked to human enterprise, the living out of our human nature. Our unique human nature affords our species a level of dignity and respect that deserves defending. This is the heart of bioethics as it applies to humans, or at least it should be. In order to determine if a new technology or movement is ethical or unethical, a primary question should always be whether it will compromise human nature and whether it will promote or demean human dignity. While concrete definitions of human nature and human dignity are elusive, many (particularly those who defend human enhancement) posit that our unique human nature is tied to our intelligence and the autonomy that is born out of that intelligence.[41] It may seem logical to conclude that if intelligence is the core of human nature then it is characteristics such as intelligence and autonomy that confer dignity on human beings. However, such a view of human nature and how it relates to human dignity is grossly oversimplified and blurs important distinctions. Furthermore, it degrades the value of humans who are not autonomous (children and those with severe mental illness), as well as those with lower cognitive ability. Rather than attempting to tie human dignity to a single characteristic like this, therefore, it seems better to tie it simply to being human—that is, to human nature itself.[42] It is with this in mind, then, that we will consider just what are the ramifications of cognitive enhancing drugs for human nature and human dignity? Some advocates of human enhancement see cognitive enhancement as an advancement in human evolution that will ultimately elevate humanity beyond the confines of our current biology.[43] Such proponents see this as an enhancement of human nature. The scientists and ethicists who most strongly advocate the use of cognitive enhancing drugs by the general public usually see their use as generating positive results for all of society.[44] Greeley and Cakic see these drugs as morally equivalent to education, exercise, and good nutrition, all of which have been shown to have profound cognitive benefits and have been instrumental in shaping human intelligence and innovation. Enhancement proponents Bostrom and Ord look to eliminate opposition to enhancement technologies on a philosophical level by arguing that those who resist human enhancement are succumbing to status quo bias.[45] They claim that simply defending our current best cognitive function as “normal” is invalid and advocate cognitive enhancers as a means to establish a new “normal” level of cognition and intelligence by which to define human nature. Indeed, advocates of cognitive enhancement seem almost universally to agree that cognitive enhancement will positively affect human nature by advancing average cognitive capability and intelligence.[46]
Though none of these proponents explicitly address the concept of human dignity, the idea of raising the bar of “normal” human nature as they suggest has profound implications for how we view those who fall below that bar (either by stage of development or by ability level). Many who are concerned about the implications of human enhancement in general fear that cognitive enhancers are simply the first step on a slippery slope that ultimately leads to an undue focus on human intelligence and academic or otherwise intellectual accomplishment. They worry that this will result in the degradation of human dignity.[47] These fears manifest themselves in two main areas. The first is the potential devaluing of the mentally handicapped. If human nature is tied to intelligence and a human life is therefore valued by the measure of cognitive ability, then what is to become of those that are so far below “normal” that they cannot become “enhanced”? These individuals already suffer discrimination as a minority in utilitarian analysis, but their status runs the risk of plummeting if society over-emphasizes the importance of cognitive ability and performance. This has the potential to augment the already growing eugenic attitude toward pre-implantation genetic analysis and the use of genetic engineering to eliminate all manner of disease, even cognitive disability.
The second manifestation of the fear that cognitive enhancement may compromise human dignity is concern that the use of drugs such as methylphenidate to increase productivity will augment society’s obsession with success as the ultimate human goal. This obsession devalues the process of accomplishing things via hard work and overcoming adversity as integral to the human enterprise.[48] For example, one study has shown that while methylphenidate works to increase focus, it does so at the cost of creativity.[49] This trade-off if properly understood might demonstrate a clear social preference. Schermer argues that there is something intrinsically valuable in the pursuit of education, that the acts of studying and learning are what make us better people, not simply what we end up knowing.[50] The PCOB invests considerable eff ort arguing this point. They quote Carl Elliot’s testimony to the council in which he said,
[T]he very changes that some people may think of as unqualified ‘enhancements’ (i.e., becoming more attentive and mindful) are not quite as unqualified as they may initially think; . . . these enhancements may well be changes critical to a person’s identity, a person’s sense of who he or she is.[51]
The PCOB goes on to make the point that the use of cognitive enhancing drugs removes the ability for us to accurately assess our own performance, as their use results in the separation of achievement from the art of achieving.[52] They illustrate this point by saying,
we admire…those who overcome obstacles and struggle to try to achieve excellence... This matter of character—the merit of disciplined and dedicated striving—is surely pertinent. For character is not only the source of our deeds, but also their product. As we have already noted, healthy people whose disruptive behavior is “remedied” by pacifying drugs rather than by their own eff orts are not learning self-control; if anything, they may be learning to think it unnecessary.[53]
Using strong imagery to echo this concern, Barbara Amiel colorfully states, “we can cure a lot with a pill, but not the hellish hangover our society will get if it overdoses on magic ones attempting to cure the human condition.”[54] These are salient points. All of us can relate to the satisfaction of looking back on our own perseverance in a difficult task, and many of us would probably agree that the sense of accomplishment is less about the outcome and more about the obstacles we overcame to facilitate that outcome. The notion that hard work and the process of accomplishing are intrinsically worthwhile, intrinsically good, is deeply rooted in our common cultural perspective about the world and ourselves.
It seems inevitable, therefore, that beliefs regarding the potential effects of pharmacological cognitive enhancement on the human experience should draw the dividing line between those who desire to allow broader use of these drugs and those who desire to prohibit their use for enhancement purposes. In another installment of this discussion, which will appear in a future issue of Dignitas, we will explore a range of empirical data regarding evaluations of and dispositions toward cognitive enhancing drugs among particularly salient populations, as well as the implications of this data for appropriate approaches to cognitive enhancement in public policy.
[1] Kass, Leon, Beyond Therapy: Biotechnology and the Pursuit of Happiness. (President’s Council on Bioethics, 2003), 278.
[2] Ibid.
[3] Marrtje Schermer et al., “The Future of Psychopharmacological Enhancements: Expectations and Policies,” Neuroethics 2, no. 2 (2009): 81; Martha Farah et al., “Neurocognitive Enhancement: What Can We Do and What Should We Do?” Nature Reviews: Neuroscience 5, no. 5 (2004): 423.
[4] Nick Bostrom and Anders Sandberg, “Cognitive Enhancement: Methods, Ethics, Regulatory Challenges,” Science and Engineering Ethics 15, no. 3 (2009): 323.
[5] Schermer, 81.
[6] Simon Outram, “The Use of Methylphenidate among Students: The Future of Enhancement?” Journal of Medical Ethics 36, no. 4 (2010): 199.
[7] Ibid.
[8] Christian Teter, “Prevalence and Motives for Illicit Use of Prescription Stimulants in an Undergraduate Students Sample,” Journal of American College Health 53, no. 6 (2005): 256.
[9] Alan DeSantis et al., “Illicit Use of Prescription ADHD Medications on a College Campus: A Multimethodological Approach,” Journal of American College Health 57, no. 3 (2008): 319.
[10] 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; Chau, Vivian. “Popping Pills to Study: Neuroethics in Education,” Stanford Journal of Neuroscience 1 (2007): 19; Outram, 199.
[11] Outram, 199.
[12] Cakic, 613.
[13] Bostrom and Sandberg, 323; Farah et al., 423; Martha Farah, “Emerging Ethical Issues in Neuroscience,” Nature Neuroscience 5, no. 11 (2002): 1125; Henry Greely et al., “Towards Responsible Use of Cognitive-Enhancing Drugs by the Healthy,” Nature 456, no. 7223 (2008): 704; Simon Outram and Eric Racine, “Developing Public Health Approaches to Cognitive Enhancement: An Analysis of Current Reports,” Public Health Ethics 4, no. 1 (2011): 100.
[14] Greely, 704.
[15] Schermer et al, 82.
[16] Ibid.
[17] 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), 8.
[18] Ibid.; Schermer et al., 82.
[19] Bostrom and Roach, 9.
[20] Bostrom and Sandberg, 328.
[21] Ibid.
[22] Rob Goodman, “Cognitive Enhancement, Cheating and Accomplishment,” Kennedy Institute of Ethics Journal 20, no. 2 (2010):150-151.
[23] Ibid.; Bostrom and Sandberg, 328-329.
[24] Bostrom and Roache, 6; Cakic, 612; Greely et al., 703-704.
[25] Cakic, 612.
[26] Ibid. The name of this principle emerges from the character of the Red Queen in Lewis Carroll’s Through the Looking-Glass.
[27] Farah et al., 423.
[28] Greely et al., 703.
[29] Farah, 1125.
[30] Ibid.
[31] Bostrom and Sandberg, 323; Farah et al., 423; Farah, 1125; Greely, et al., 704; Outram and Racine, 100; Barbara Sahakian and Sharon Morein-Zamir, “Professor’s Little Helper,” Nature 450, no. 7173 (2007): 1159.
[32] Bostrom and Roache, 8.
[33] Bostrom and Sandberg, 329.
[34] Greely et al., 704.
[35] Ibid.; Sahakian and Morein-Zamir, 1159.
[36] Farah, 1128; Farah et al., 424.
[37] Leon Kass, “Ageless Bodies, Happy Souls: Biotechnology and the Pursuit of Perfection,” The New Atlantis Spring 1 (2003).
[38] William Cheshire, “Grey Matters: Just Enhancement,” Ethics & Medicine: An International Journal of Bioethics 26, no. 1 (2010), http://cbhd.org/content/grey-matters-just-enhancement (accessed August 12, 2013); C. Ben Mitchell et al., Biotechnology and the Human Good. (Washington, D.C.: Georgetown University Press, 2007).
[39] Schermer et al., 80-81.
[40] Immaculada de Melo-Martin, “Defending Human Enhancement Technologies: Unveiling Normativity,” Journal of Medical Ethics 36, no. 8 (2010): 485.
[41] Søren Holm, “The Nature of Human Welfare” in Future Perfect? God, Medicine and Human Identity, ed. Celia Deane-Drummond and Peter Manley Scott (New York: T&T Clark, 2010), 44.
[42] Mitchell et al., 68.
[43] John Harris, Enhancing Evolution: The Ethical Case for Making Better People (Princeton: Princeton University Press, 2007) 29.
[44] Greely, 704.
[45] Nick Bostrom and Tony Ord, “The Reversal Test: Eliminating Status Quo Bias in Applied Ethics,” Ethics 116, no. 4 (2006): 658.
[46] Harris, 8.
[47] Leon Kass, Life, Liberty and the Defense of Dignity (San Francisco: Encounter, 2002), 18; Mitchell et al., 127.
[48] Ibid., 93.
[49] Martha Farah, Caroline Haimm, Geena Sankoorikal, and Anjan Chatterjee, “When We Enhance Cognition with Adderall, Do We Sacrifice Creativity? A Preliminary Study,” Psychopharmacology 202, no. 1-3 (2009): 541.
[50] Marrtje Schermer, “On the Argument that Enhancing Is ‘Cheating’,” Journal of Medical Ethics 34, no. 2 (2008): 88.
[51] Kass, 90-91.
[52] Ibid., 93.
[53] Ibid., 291.
[54] Barbara Amiel, “Is Ritalin Giving Some Kids an Unfair Boost?” Maclean’s, January 28, 2008, 12.
Susan Rouse, "Cognitive Enhancement in Education: The State of the Issue,” Dignitas 20, no. 3 (2013): 6–11.
