They are trying to snag us all.

[Guest guest]

Here is a long read for anyone intersted that shows just how real the

threat of the pharmaceutical industry is becoming. Notice a few key

words in this long read (like coercion).

http://www.redflagsweekly.com/flash.htm

May 27, 2004

BRAIN ENHANCEMENT - STATE OF THE ART?

Are you already feeling pressured to give your mental processes a boost?

It is likely that in the foreseeable future many people will be urged -

by employers, by family members - to boost their brain potential,

particularly via the drug route. What about safety? And what will be

morally acceptable in this new world? Of course, you might wonder if

much of this is still science fiction. The article from Nature that is

featured here is by no means a perfect look at what is occurring. RFD

does not endorse any particular statements in this piece, but we chose

it because it provides an example of how conventional medicine is

viewing brain enhancement. RFD, in fact, views all forms of drug use in

highly critical terms, assessing risks and benefits and strongly raising

major questions particularly about psychiatric drugs and their vast

overuse. This piece from Nature, however, does raise some important

ethical issues that will become increasingly important to debate. It is

worthwhile to read

it in its entirety.

http://www.nature.com/cgi-taf/DynaPage.taf?file=/nrn/journal/v5/n5/full/nrn1390_\

fs.html

Science and Society

NEUROCOGNITIVE ENHANCEMENT: WHAT CAN WE DO AND WHAT SHOULD WE DO?

Martha J. Farah1, Judy Illes2, Cook-Deegan3, Gardner4,

Kandel5, King6, Parens7, Barbara Sahakian8 &

Root Wolpe9 about the authors

1 Martha Farah is at the Center for Cognitive Neuroscience, University

of Pennsylvania, 3720 Walnut Street, Philadelphia, Pennsylvania 19104, USA

2 Judy Illes is at the Stanford Center for Biomedical Ethics and the

Department of Radiology, 701 Welch Road, Stanford, California

94304-5748, USA

3 Cook-Deegan is at the Center for Genome Ethics, Law and Policy,

Institute for Genome Sciences and Policy and Department of Public Policy

Studies, Duke University, Room 127C, North Building, Research Drive, Box

90141, Durham, North Carolina 27708-0141, USA

4 Gardner is at the Graduate School of Education, Harvard

University, Roy E. Larsen Hall, 2nd Floor, Appian Way, Cambridge,

Massachusetts 02138, USA

5 Kandel is at the Center for Neurobiology and Behavior, Columbia

University and Medical Institute, 1051 Riverside Drive,

New York, New York 10032, USA

6 King is at the town University Law Center, 600 New

Jersey Avenue, NW Washington DC 20001, USA

7 Parens is at the The Hastings Center, 21 Malcolm Gordon Drive,

Garrison, New York 10524-5555, USA

8 Barbara Sahakian is at the Department of Psychiatry, University of

Cambridge, Addenbrooke's Hospital (Box 189), Cambridge CB2 2QQ, UK

9 Root Wolpe is at the Departments of Psychiatry, Medical Ethics,

and Sociology, Center for Bioethics, University of Pennsylvania, 3401

Market Street, Philadelphia, Pennsylvania 19104-3319, USA

correspondence to:

Martha J. Farah mfarah@... <mailto:mfarah@...>

Judy Illes illes@... <mailto:illes@...>

Our growing ability to alter brain function can be used to enhance the

mental processes of normal individuals as well as to treat mental

dysfunction in people who are ill. The prospect of neurocognitive

enhancement raises many issues about what is safe, fair and otherwise

morally acceptable. This article resulted from a meeting on

neurocognitive enhancement that was held by the authors. Our goal is to

review the state of the art in neurocognitive enhancement, its attendant

social and ethical problems, and the ways in which society can address

these problems.

Many are predicting that the twenty-first century will be the century of

neuroscience. Humanity's ability to alter its own brain function might

well shape history as powerfully as the development of metallurgy in the

Iron Age, mechanization in the Industrial Revolution or genetics in the

second half of the twentieth century. This possibility calls for an

examination of the benefits and dangers of neuroscience-based

technology, or 'neurotechnology', and consideration of whether, when and

how society might intervene to limit its uses.

At the turn of the century, neurotechnology spans a wide range of

methods and stages of development. Brain-machine interfaces that allow

direct two-way interaction between neural tissue and electronic

transducers remain in the 'proof of concept' stage, but show substantial

promise1. Neurosurgery is increasingly considered as a treatment for

mental illnesses and an array of new procedures are under development,

including the implantation of devices and tissue2. Non-invasive

transcranial magnetic stimulation (TMS) of targeted brain areas is the

basis of promising new treatments for depression and other psychopathology3.

On the leading edge of neurotechnology is psychopharmacology. Our

ability to achieve specific psychological changes by targeted

neurochemical interventions, which began through a process of

serendipity and trial and error in the mid-twentieth century, is

evolving into the science of rational drug design. The psychopharmacopia

of the early twenty-first century encompasses both familiar, and in some

cases highly effective, drugs, and a new generation of more selective

drugs that target the specific molecular events that underlie cognition

and emotion4. For the most part, these drugs are used to treat

neurological and psychiatric illnesses, and there is relatively little

controversy surrounding this use. However, psychopharmacology is also

increasingly used for 'enhancement' - that is, for improving the

psychological function of individuals who are not ill.

The enhancement of normal neurocognitive function by pharmacological

means is already a fact of life for many people in our society, from

elementary school children to ageing baby boomers. In some school

districts in the United States the proportion of boys taking

methylphenidate exceeds the highest estimates of the prevalence of

attention deficit-hyperactivity disorder (ADHD)5, implying that normal

childhood boisterousness and distractibility are being targeted for

pharmacological intervention. The use of prescription stimulants (such

as methylphenidate and dextroamphetamine) as study aids by high school

and college students who do not have ADHD has recently drawn attention,

and might include as many as 16% of the students on some campuses6.

Sales of nutritional supplements that promise improved memory in middle

age and beyond have reached a billion dollars annually in the United

States alone7, despite mixed evidence of effectiveness8. In contrast to

the other neurotechnologies

mentioned earlier, whose potential use for enhancement is still

hypothetical, pharmacological enhancement has already begun.

What can we do?

Many aspects of psychological function are potential targets for

pharmacological enhancement, including memory, executive function, mood,

appetite, libido and sleep9, 10. We will use the first two of these,

memory and executive function, as examples to show the state of the art

in psychopharmaceutical enhancement, the ethical issues raised by such

enhancement and the policy implications of these ethical issues. A brief

review of the state of the art in neurocognitive enhancement is offered

here; additional information is freely available to readers of this

article at www.nyas.org/ebrief/neuroethics

<http://www.nyas.org/ebrief/neuroethics> and in recent articles by

Rose11, Lynch12 and Hall7.

Memory enhancement. Memory enhancement is of interest primarily to older

adults. The ability to encode new memories declines measurably from the

third decade of life onwards, and by the fourth decade the decline can

become noticeable and bothersome to normal healthy individuals13. Memory

difficulties in middle or old age are not necessarily a harbinger of

future dementia but can be part of the normal pattern of cognitive

ageing, which does not make it any less inconvenient when we misplace

our glasses or forget the name of a recent acquaintance. What can

current and imminent neurotechnologies offer us by way of help?

The changes that underlie normal age-related declines in memory probably

differ from those that underlie Alzheimer's disease, indicating that the

optimal pharmacological approaches to therapy and enhancement might also

differ. Although donepezil, a cholinesterase inhibitor that is used to

treat Alzheimer's disease, did enhance performance in one study of

healthy middle-aged pilots after flight simulator training14, drug

companies are looking elsewhere for pharmacological approaches to memory

enhancement in normal individuals. Recent advances in the molecular

biology of memory have presented drug designers with many entry points

through which to influence the specific processes of memory formation,

potentially redressing the changes that underlie both normal and

pathological declines in memory. Most of the candidate drugs fall into

one of two categories: those that target the initial induction of

long-term potentiation and those that target the later stages of memory

consolidation. In

the first category are drugs that modulate AMPA

(-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid) receptors to

facilitate depolarization, including Cortex Pharmaceuticals'

Ampakines12. In the second category are drugs that increase CREB (the

cAMP response element-binding protein), a molecule that in turn

activates genes to produce proteins that strengthen the synapse. One

such drug is the molecule MEM1414, which is being tested by Memory

Pharmaceuticals7 (a company co-founded by one of the authors (E.K)).

The pursuit of mastery over our own memories includes erasing

undesirable memories as well as retaining desirable ones. Traumatic

events can cause lifelong suffering by the intrusive memories of

post-traumatic stress disorder (PTSD), and methods are being sought to

prevent the consolidation of such memories by pharmacological

intervention immediately after the trauma15. Drugs whose primary purpose

is to block memories are also being developed by the pharmaceutical

industry7. Extending these methods beyond the victims of trauma, to

anyone who wishes to avoid remembering an unpleasant event, is another

way in which the neural bases of memory could be altered to enhance

normal function.

Enhancement of executive function. Executive function refers to

abilities that enable flexible, task-appropriate responses in the face

of irrelevant competing inputs or more habitual but inappropriate

response patterns. These include the overlapping constructs of

attention, working memory and inhibitory control. Drugs that target the

dopamine and noradrenaline neurotransmitter systems are effective at

improving deficient executive function, for example in ADHD, and have

recently been shown to improve normal executive function as well16, 17.

For example, one of the authors (B.J.S.) found that healthy young

volunteers performed the Tower of London problem-solving task more

accurately after being given methylphenidate than after being given a

placebo when the task was novel16. Methylphenidate also increased

accuracy in a complex spatial working memory task, and this was

accompanied by a reduction in the activation of areas of the brain that

are related to working memory, as shown by positron emission tomography

(PET)17. For the latter task, the amount of benefit was inversely

proportional to the volunteers' working memory capacity as assessed by a

different working memory task, digit span, with little or no benefit to

those with the highest digit span performances. This is of interest in

discussions of enhancement, because it indicates that, for this

medication and this cognitive ability at least, those with lower levels

of performance are more likely to benefit from enhancement than those

with higher levels. Indeed, it is

possible that some drugs would compress the normal range of performance

in both directions. One of the authors (M.J.F.) found that the dopamine

agonist bromocriptine improved performance on various executive function

tasks for individuals with lower- than-average working memory capacity,

but lowered the performance of those with the highest working memory

capacities18. Whether enhancement can boost the performance of already

high-performing individuals must be determined empirically for each drug

and for each type of cognitive ability.

Newer drugs might improve executive function in different ways,

influencing different underlying processes and interacting in different

ways with individual differences (for example, in working memory

capacity) and states (such as restedness). The newest potential

neurocognitive enhancer is the drug modafinil, which is approved for the

treatment of narcolepsy and is increasingly prescribed off-label for

other purposes19. One of the authors (B.J.S.) found that it increases

performance among healthy young adults on a set of executive function

tasks that differs partly from those that are influenced by

methylphenidate, with its effects resulting at least in part from an

improved ability to inhibit impulsive responses20.

What should we do?

Ethical problems and policy solutions. Neurocognitive enhancement raises

ethical issues for many different constituencies. These include academic

and industry scientists who are developing enhancers, and physicians who

will be the gatekeepers to them, at least initially. Also included are

individuals who must choose to use or not to use neurocognitive

enhancers themselves, and parents who must choose to give them or not to

give them to their children. With the advent of widespread

neurocognitive enhancement, employers and educators will also face new

challenges in the management and evaluation of people who might be

unenhanced or enhanced (for example, decisions to recommend enhancement,

to prefer natural over enhanced performance or vice versa, and to

request disclosure of enhancement). Regulatory agencies might find their

responsibilities expanding into considerations of 'lifestyle' benefits

and the definition of acceptable risk in exchange for such benefits.

Finally, legislators

and the public will need to decide whether current regulatory

frameworks are adequate for the regulation of neurocognitive

enhancement, or whether new laws must be written and new agencies

commissioned.

To focus our discussion, we will dispense with some ethical issues that

are important but not specific to neurocognitive enhancement. The first

such issue is research ethics. Research on neurocognitive enhancement,

as opposed to therapy, raises special considerations mainly insofar as

the potential benefits can be viewed as smaller, and acceptable levels

of risk to research subjects would be accordingly lower. This

consideration is largely academic for those neurocognitive enhancers

that come to market first as therapies for recognized medical

conditions, which includes all of the substances that are now available

for enhancement, although this might not be true in the future. Another

important ethical issue concerns the use of neurocognitive enhancement

in the criminal justice system, in which a large proportion of offenders

fall in the lower range of cognitive ability in general21 and executive

inhibitory control in particular22. Although neurocognitive enhancement

brings with it

the potential for subtle coercion in the office or classroom,

'neurocorrection' is more explicitly coercive and raises special issues

of privacy and liberty that will not be discussed here. Finally, the

ethical problems that are involved in parental decision-making on behalf

of minor children are complex and enter into the ethics of

neurocognitive enhancement in school children, but will not be discussed

here.

The remaining issues can be classified and enumerated in various ways.

Four general categories will be used here to organize our discussion of

the ethical challenges of neurocognitive enhancement and possible

societal responses.

Safety. The idea of neurocognitive enhancement evokes unease in many

people, and one source of the unease is concern about safety. Safety is

a concern with all medications and procedures, but our tolerance for

risk is smallest when the treatment is purely elective. Furthermore, in

comparison to other comparably elective treatments such as cosmetic

surgery, neurocognitive enhancement involves intervening in a far more

complex system, and we are therefore at greater risk of unanticipated

problems. Would endowing learners with super-memory interfere with their

ability to understand what they have learned and relate it to other

knowledge? Might today's Ritalin users face an old age of premature

cognitive decline? The possibility of hidden costs of neurocognitive

enhancement might be especially salient because of our mistrust of

unearned rewards, and the sense that such opportunities can have

Faustian results.

With any drug, whether for therapy or enhancement, we can never be

absolutely certain about the potential for subtle, rare or long-term

side effects. Instead, our regulatory agencies determine what

constitutes a sufficiently careful search for side effects and what side

effects are acceptable in view of a drug's benefits. Although consensus

will have to be developed on these issues in connection with

neurocognitive enhancement, we see no reason that the same approach

cannot be applied here.

Coercion. If neurocognitive enhancement becomes widespread, there will

inevitably be situations in which people are pressured to enhance their

cognitive abilities. Employers will recognize the benefits of a more

attentive and less forgetful workforce; teachers will find enhanced

pupils more receptive to learning. What if keeping one's job or

remaining in one's school depends on practicing neurocognitive

enhancement? Such dilemmas are difficult but are not without useful

legal precedent. Many of the relevant issues have been addressed in

legislation such as Connecticut's Statute " Policies regarding the

recommendation of psychotropic drugs by school personnel " 23 and case law

such as versus Derry ative School District24.

Of course, coercion need not be explicit. Merely competing against

enhanced co-workers or students exerts an incentive to use

neurocognitive enhancement, and it is harder to identify any existing

legal framework for protecting people against such incentives to

compete. But would we even want to? The straightforward legislative

approach of outlawing or restricting the use of neurocognitive

enhancement in the workplace or in school is itself also coercive. It

denies people the freedom to practice a safe means of self-improvement,

just to eliminate any negative consequences of the (freely taken) choice

not to enhance.

Distributive justice. It is likely that neurocognitive enhancement, like

most other things, will not be fairly distributed. Ritalin use by normal

healthy people is highest among college students, an overwhelmingly

middle-class and privileged segment of the population. There will

undoubtedly be cost barriers to legal neurocognitive enhancement and

possibly social barriers as well for certain groups. Such barriers could

compound the disadvantages that are already faced by people of low

socioeconomic status in education and employment. Of course, our society

is already full of such inequities, and few would restrict advances in

health or quality of life because of the potential for inequitable

distribution. Unequal access is generally not grounds for prohibiting

neurocognitive enhancement, any more than it is grounds for prohibiting

other types of enhancement, such as private tutoring or cosmetic

surgery, that are enjoyed mainly by the wealthy. Indeed, in principle

there is no reason

that neurocognitive enhancement could not help to equalize opportunity

in our society. In comparison with other forms of enhancement that

contribute to gaps in socioeconomic achievement, from good nutrition to

high-quality schools, neurocognitive enhancement could prove easier to

distribute equitably.

Personhood and intangible values. Enhancing psychological function by

brain intervention is in some ways like improving a car's performance by

making adjustments to the engine. In both cases the goal is to improve

function, and to the extent that we succeed without compromising safety,

freedom of choice or fairness we can view the result as good. But in

other ways the two are very different, because modifying brains, unlike

engines, affects persons. The fourth category of ethical issue

encompasses the many ways in which neurocognitive enhancement intersects

with our understanding of what it means to be a person, to be healthy

and whole, to do meaningful work, and to value human life in all its

imperfection. The recent report of the President's Council on

Bioethics25 emphasizes these issues in its discussion of enhancement.

Attempts to derive policies from these considerations must contend with

the contradictory ways in which different values are both challenged and

affirmed by neurocognitive enhancement. For example, we generally view

self-improvement as a laudable goal. At the same time, improving our

natural endowments for traits such as attention span runs the risk of

commodifying them. We generally encourage innovations that save time and

effort, because they enable us to be more productive and to direct our

efforts towards potentially more worthy goals. However, when we improve

our productivity by taking a pill, we might also be undermining the

value and dignity of hard work, medicalizing human effort and

pathologizing a normal attention span. The self-transformation that we

effect by neurocognitive intervention can be seen as self-actualizing,

or as eroding our personal identity. Neither the benefits nor the

dangers of neurocognitive enhancement are trivial.

In weighing the dangers of neurocognitive enhancement against its

benefits, it is important to note the many ways in which similar

tradeoffs are already present in our society. For example, the

commodification of human talent is not unique to Ritalin-enhanced

executive ability. It is probably more baldly on display in books and

classes that are designed to prepare preschoolers for precocious

reading, music or foreign language skills, but many loving parents seek

out such enrichment for their children. Americans admire the effort that

was expended in Abraham Lincoln's legendary four-mile walk to school

every day, but no-one would do that (or want their child to do that) if

a bus ride were available. Medicalization has accompanied many

improvements in human life, including improved nutrition and family

planning. And if we are not the same person on Ritalin as off, neither

are we the same person after a glass of wine as before, or on vacation

as before an exam. As these examples show,

many of our 'lifestyle' decisions end up on the right side of one value

and the wrong side of another, but this does not necessarily mean that

these decisions are wrong.

Disentangling moral principle and empirical fact. Since pre-Socratic

times, philosophers have sought ways of systematizing our ethical

intuitions, to identify a set of guiding principles that could be

applied in any situation to dictate the right course of action. All of

us have ethical intuitions about most situations; one goal of ethics is

to replace case-by-case intuitions with principled decisions. A

practical social advantage of ethical principles is that they can

provide guidance when intuitions are unclear or inconsistent from person

to person. The success of an ethical discussion depends on the

discussants' ability to articulate the relevant principles as well as

the relevant facts about a situation to which the principles apply.

In the ethics of neurocognitive enhancement we are still feeling our way

towards the relevant principles and we still have much to learn about

the relevant facts. Is it a matter of principle that 'medicalization' is

bad, or that hard work confers 'dignity'? Or are these moral heuristics,

rules of thumb that might be contradicted in some cases? And is it a

matter of fact that Ritalin reduces our opportunities to learn

self-discipline, or could it in fact have no effect or even help us in

some way? Until we have disentangled the a priori from the empirical

claims, and evaluated the empirical claims more thoroughly, we are at

risk of making wrong choices.

When not to decide is to decide. Neurocognitive enhancement is already a

fact of life for many people. Market demand, as measured by sales of

nutritional supplements that promise cognitive enhancement, and ongoing

progress in psychopharmacology portend a growing number of people

practicing neurocognitive enhancement in the coming years. In terms of

policy, we will soon reach the point where not to decide is to decide.

Continuing our current laissez-faire approach, with individuals relying

on their physicians or illegal suppliers for neurocognitive enhancement,

risks running afoul of public opinion, drug laws and physicians' codes

of ethics. The question is therefore not whether we need policies to

govern neurocognitive enhancement, but rather what kind of policies we

need. The choices range from minimal measures, such as raising public

awareness of the potential practical and moral difficulties of

neurocognitive enhancement, to the wholesale enacting of new laws and

the creation of

new regulatory agencies. In between these extremes lie a host of other

options, for example the inclusion of neurocognitive enhancement

policies in codes of ethics of the professional organizations of

physicians, scientists, human resource managers and educators, and

short-term moratoria on neurocognitive enhancement.

Francis Fukuyama26 has argued for new legislation to control the use of

neurocognitive enhancement, among other biotechnologies. He

characterizes the work of groups such as the President's Council on

Bioethics in the USA and the European Group on Ethics in Science and New

Technology as the " intellectual spade work of thinking through the moral

and social implications of biomedical research " , and suggests that " it

is time to move from thinking to acting, from recommending to

legislating. We need institutions with real enforcement powers. "

We admit to being less certain about the right course of action. With

respect to the first three categories of issue, concerning safety,

freedom and fairness, current laws and customs already go a long way

towards protecting society. With respect to the fourth category of

issue, we believe that there is much more 'spade work' (in Fukuyama's

words) to be done in sorting out the moral and social implications of

neurocognitive enhancement before we move from recommendations to

legislation. We should draw an object lesson from the history of federal

stem cell legislation in the USA, which was enacted hastily in the wake

of reported attempts at human reproductive cloning with limited public

understanding of the issues. That legislation is now viewed by many as a

setback for responsible biomedical research, and two states have now

enacted their own laws to permit a wider range of research activity.

The need for more discussion of the issues is a predictable conclusion

for an article like this one, but nevertheless a valid one. One urgent

topic for discussion is the role of physicians in neurocognitive

enhancement27. Although western medicine has traditionally focused on

therapy rather than enhancement, exceptions are well established.

Cosmetic surgery is the most obvious example, but dermatology, sports

medicine and fertility treatments also include enhancement among their

goals. Enabling a young woman to bank her eggs to allow later

childbearing, for example, is not therapeutic but enhancing. Will

neurocognitive enhancement join these practices? If so, will it be

provided by specialists or family practitioners? What responsibility

will physicians take for the social and psychological impact of the

enhancements they prescribe, and by what means (for example, informal or

formal psychological screening as used by cosmetic surgeons or fertility

specialists)?

Beyond these immediate practical issues, we must clarify the intangible

ethical issues that apply to neurocognitive enhancement. This requires

interdisciplinary discussion, with neuroscientists available to identify

the factual assumptions that are implicit in the arguments for and

against different positions, and ethicists available to articulate the

fundamental moral principles that apply. As a society we are far from

understanding the facts and identifying the relevant principles. With

many of our college students already using stimulants to enhance

executive function and the pharmaceutical industry soon to be offering

an array of new memory-enhancing drugs, the time to begin this

discussion is now.

Links

FURTHER INFORMATION

Martha Farah's homepage | Judy Illes's homepage | Gardner's

homepage | Kandel's laboratory | King's homepage | Barbara

Sahakian's homepage | Root Wolpe | NYAS e-briefing on neuroethics

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Acknowledgements

This paper is based, in part, on a meeting held at the New York Academy

of Sciences in June 2003, supported by a grant to J.I. from the National

Science Foundation with co-sponsorship of a Mushett Family Foundation

grant to the Academy. The writing of this paper was supported by NSF and

NIH grants to M.J.F. and an NIH grant and a Greenwald Foundation grant

to J.I.

Competing interests statement. The authors declare competing financial

interests.Declaration of competing financial interests

Martha J. Farah, Judy Illes, Cook-Deegan, Gardner,

Kandel, King, Parens, Barbara Sahakian & Root Wolpe

Neurocognitive enhancement: what can we do and what should we do?.

Nature Reviews Neuroscience 5, 421-425 (2004); doi:10.1038/nrn1390

Declaration: E.K. is a co-founder and Chariman of the scientific board

of directors of Memory Pharmaceuticals.

--

Peace, love and light,

Don Quai

" Spirit sleeps in the mineral, breathes in the vegetable, dreams in the animal

and wakes in man. "