Hype is ethical concern with cognitive enhancers
"There is still a lot to be proven"
Recent trends demonstrate a widening use of drugs that can facilitate cognitive capability, both in patient and general-use populations, says James Giordano, PhD, chief of the Neuroethics Studies Program at Edmund D. Pellegrino Center for Clinical Bioethics at Georgetown University Medical Center in Washington, DC.
However, there is "much more hype than evidence" that medications used to treat Alzheimer's disease and other cognitive deficits also may improve cognition in healthy individuals, says Jonathan D. Moreno, PhD, David and Lyn Silfen University Professor of Ethics at University of Pennsylvania in Philadelphia.
"Color me a skeptic," he says. "There really aren't many better ways to enhance cognition than a good night's sleep, a healthy diet, and, for some people, a nice cup of coffee." Moreno says that for methyphenidate and amphetamine, there is "very mixed evidence about enhancement. It may be that it works better for people who are closer to a standard deviation rather than a real enhancement."
As for more radical methods of enhancement, such as transcranial magnetic stimulation, Moreno notes that there are safety concerns about repeat exposure. "Nor is there really good evidence that people are enhanced by these things," he says. "There is still a lot to be proven, and little evidence of efficacy, and ethical medicine requires more than a hunch. It probably requires more than a series of anecdotes that you accumulate in your practice."
Some physicians have strong feelings about one treatment or another, even though there is not a lot of data, but any off-label use must have some rational basis, adds Moreno. "There probably will be a time when some of this stuff will work, but people need to appreciate that we are really far from good evidence," he says. "We may find there are physiological limitations for how much you can enhance cognition."
Moreno says that while off-label use isn't necessarily unethical, caution is advisable. "For example, external neuromodulation is being employed on a 'do-it-yourself' basis as a matter of curiosity," he says. "Even if there are short-term enhancements and it would be necessary to do carefully controlled studies to make sure the long-term risks are still a question. If a physician prescribed that sort of treatment for enhancement outside of a clinical trial, I would be concerned."
One ethical concern involves whether unique capacities or advantages are obtained by those who take these agents, and the equitable distribution of these drugs to various individuals and groups in society. "It's hard to make the justice argument for this when there are so many other inequalities not everyone can afford math tutors for kids, for example," says Moreno. "In terms of applied ethics, it's hard to single out one advantage from another."
There is a more fundamental issue that arises from the use of cognitive enhancing drugs namely, that there is still much that remains unknown about the neural mechanisms thatfunctionin cognition, says Giordano. This raises a number of ethical concerns, he says, including the fidelity of informed consent; what responsibilities for care of unexpected consequences of use should be borne by clinicians, healthcare institutions, and pharmaceutical companies; and whether adequate or sufficient Guidelines, policies, and laws are needed to govern the right and good use of such interventions.
The debate over whether use of cognitive enhancers is inherently unethical typically hinges on whether these drugs represent treatments or enhancements, says Giordano. "In many ways, this hinges upon the nature of the 'good' that is being sought through the use of such drugs," Giordano says.
This also raises the issue of how society views the use of various implements such as caffeinated beverages, dietary supplements, and pharmaceuticals in relation to cultural norms, he says. "While one possibility is that cognitive enhancers will create new norms of human cognitive capability, another is that the availability and use of these agents may only serve to widen the gap between the proverbial 'haves' and 'have nots' of society," adds Giordano.1
Long-term consequences of use andpotentialmisuse of cognitive enhancers are as yet unknown, says Giordano.2 "This certainly compels the need for additional research and prudence in their employment, so as to enable both ongoing re-assessment of the benefits, burdens, and risks, and the development of iterative, well-informed bioethical Guidelines to steer their sound utilization in clinical practice," he says.
The goal is not necessarily to be proscriptive, but to address how benefits might be maximized while reducing burdens and risks. "Key to this process is the identification and analysis of gaps in information and/or capability," says Giordano. "These must be addressed so as to plan and be prepared for the likely ethical, legal, and social contingencies that will arise."
1. Giordano J, Benedikter R. An early and necessary flight of the Owl of Minerva: Neuroscience, neurotechnology, human socio-cultural boundaries, and the importance of neuroethics. J. Evolution and Technol. 2012;22(1):14-25.
2. Gini A, Rossi J, Giordano J. Considering enhancement and treatment: On the need to regard contingency and develop dialectic evaluation. American Journal of Bioethics-Neuroscience 2010;1(1):25-27.
- James Giordano, PhD, Chief, Neuroethics Studies Program, Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC. Phone: (202) 687-1160. Email: firstname.lastname@example.org.
- Jonathan D. Moreno, PhD, David and LynSilfenUniversity Professor of Ethics, University of Pennsylvania, Philadelphia. Phone: (215) 898-7136. Email: email@example.com.