Whose well-being? Common conceptions and misconceptions in the enhancement debate

Neuroenhancement as Instrumental Drug Use: Putting the Debate in a Different Frame

The use of performance-enhancing drugs to study or work better is often called "cognitive enhancement" or "neuroenhancement" and sparked a debate between scholars from many disciplines. I argue that such behavior can better be subsumed under the more general category of "instrumental drug use". This broader perspective allows understanding neuroenhancement better from the perspective of addiction medicine and public health and supports a more consistent drug policy. I also summarize the most important systematic reviews and individual surveys of nonmedical substance use to study or work better. Different definitions and methodologies limit the comparability of these studies. The unified approach of drug instrumentalization would partially solve such problems. Finally, prevalence studies from the 1960s to 1980s as well as anecdotal evidence since the late 19th century show that instrumental drug use is and has been for a long time a common phenomenon. It should thus also be investigated and treated accordingly.

Hacking the Brain: Dimensions of Cognitive Enhancement

In an increasingly complex information society, demands for cognitive functioning are growing steadily. In recent years, numerous strategies to augment brain function have been proposed. Evidence for their efficacy (or lack thereof) and side effects has prompted discussions about ethical, societal, and medical implications. In the public debate, cognitive enhancement is often seen as a monolithic phenomenon. On a closer look, however, cognitive enhancement turns out to be a multifaceted concept: There is not one cognitive enhancer that augments brain function per se, but a great variety of interventions that can be clustered into biochemical, physical, and behavioral enhancement strategies. These cognitive enhancers differ in their mode of action, the cognitive domain they target, the time scale they work on, their availability and side effects, and how they differentially affect different groups of subjects. Here we disentangle the dimensions of cognitive enhancement, review prominent examples of cognitive enhancers that differ across these dimensions, and thereby provide a framework for both theoretical discussions and empirical research.

How Realistic Are the Scientific Assumptions of the Neuroenhancement Debate? Assessing the Pharmacological Optimism and Neuroenhancement Prevalence Hypotheses

Since two decades, neuroenhancement is a major topic in neuroethics and still receives much attention in the scholarly literature as well as in public media. In contrast to high hopes at the beginning of the “Decade of the Brain” in the United States and Europe that we subsume under the “pharmacological optimism hypothesis,” recent evidence from clinical neuroscience suggests that developing drugs that make healthy people smarter is even more difficult than finding new treatments for patients with mental disorders. However, cognitive enhancing drugs even for patients with impaired intellectual performance have not been successfully developed yet and new drugs that might have a disruptive impact on this field are unlikely to be developed in the near future. Additionally, we discuss theoretical, empirical, and historical evidence to assess whether cognitive enhancement of the healthy is common or even epidemic and if its application will further increase in the near future, as suggested by the “neuroenhancement prevalence hypothesis.” Reports, surveys, and reviews from the 1930s until today indicate that psychopharmacological neuroenhancement is a fact but less common than often stated, particularly in the public media. Non-medical use of psychostimulants for the purpose of cognitive enhancement exists since at least 80 years and it might actually have been more common in the past than today. Therefore, we conclude that the pharmacological optimism hypothesis and neuroenhancement prevalence hypotheses have to be rejected and argue that the neuroenhancement debate should take the available evidence more into account.

Transcranial Electrical Stimulation to Enhance Cognitive Performance of Healthy Minors: A Complex Governance Challenge

An increasing number of healthy adolescents are consuming products that can enhance their cognitive performance in educational settings. Currently, the use of pharmaceuticals is the most widely discussed enhancement method in the literature, but new evidence suggests that other methods based on Transcranial Electrical Stimulation (tES) also have potential as cognitive enhancer. Just like pharmaceutical enhancers, the availability and education-related use of tES-devices raise a broad range of ethical, legal, and societal issues that need to be addressed by policy-makers. Few studies, however, have specifically explored these issues in relation to child wellbeing. In this narrative review with systematic search, we describe the issues for child wellbeing that could arise from the availability and education-related use of tES-based enhancers by healthy minors. We demonstrate that the issues form a complex web of uncertainties and concerns, which are mainly incited by two factors. First is the high level of factual uncertainty due to gaps in empirical evidence about the exact working mechanisms and efficacy of tES. Moreover, a lack of insight into the technique’s (long-term) effects on healthy developing brains, and uncertainties about potential cognitive trade-offs have fueled concerns about the technique’s safety and impact. The second factor that contributes to the complexity of issues is the presence of moral diversity in our society. Different opinions exist on whether a certain enhancement effect would be desirable and whether potential risks would be acceptable. These opinions depend on one’s moral perspective, and the way one interprets and weights values such as the child’s autonomy and authenticity. The challenge for proper governance resides in the design of an appropriate framework that is capable of balancing the different moral perspectives in society, while recognizing the uncertainties that still exist. We therefore argue for a responsible innovation approach, which encourages an adaptive attitude toward emerging knowledge and dynamic societal values, to deal with the identified issues regarding tES-based enhancement appropriately.

tDCS for Memory Enhancement: Analysis of the Speculative Aspects of Ethical Issues

Transcranial direct current stimulation (tDCS) is a promising technology to enhance cognitive and physical performance. One of the major areas of interest is the enhancement of memory function in healthy individuals. The early arrival of tDCS on the market for lifestyle uses and cognitive enhancement purposes lead to the voicing of some important ethical concerns, especially because, to date, there are no official guidelines or evaluation procedures to tackle these issues. The aim of this article is to review ethical issues related to uses of tDCS for memory enhancement found in the ethics and neuroscience literature and to evaluate how realistic and scientifically well-founded these concerns are? In order to evaluate how plausible or speculative each issue is, we applied the methodological framework described by Racine et al. (2014) for “informed and reflective” speculation in bioethics. This framework could be succinctly presented as requiring: (1) the explicit acknowledgment of factual assumptions and identification of the value attributed to them; (2) the validation of these assumptions with interdisciplinary literature; and (3) the adoption of a broad perspective to support more comprehensive reflection on normative issues. We identified four major considerations associated with the development of tDCS for memory enhancement: safety, autonomy, justice and authenticity. In order to assess the seriousness and likelihood of harm related to each of these concerns, we analyzed the assumptions underlying the ethical issues, and the level of evidence for each of them. We identified seven distinct assumptions: prevalence, social acceptance, efficacy, ideological stance (bioconservative vs. libertarian), potential for misuse, long term side effects, and the delivery of complete and clear information. We conclude that ethical discussion about memory enhancement via tDCS sometimes involves undue speculation, and closer attention to scientific and social facts would bring a more nuanced analysis. At this time, the most realistic concerns are related to safety and violation of users’ autonomy by a breach of informed consent, as potential immediate and long-term health risks to private users remain unknown or not well defined. Clear and complete information about these risks must be provided to research participants and consumers of tDCS products or related services. Broader public education initiatives and warnings would also be worthwhile to reach those who are constructing their own tDCS devices.

Prevalence of and motives for pharmacological neuroenhancement in Switzerland--results from a national Internet panel

AIMS

To estimate the prevalence of self-reported pharmacological neuroenhancement (PNE) with prescription or recreational drugs among the Swiss general population and correlates of PNE.

DESIGN

A population-based cross-sectional study using a self-administered online survey.

SETTING

A telephone-recruited highly representative internet panel in Switzerland.

PARTICIPANTS

A total of 10,171 Swiss employees and students (unweighted n = 10,084) aged 15-74 years (mean age: 39.1 ± 13.3; 46.6% female).

MEASUREMENTS

Self-reported life-time, past-year and past-month use of prescription or recreational drugs for PNE, motives for use and correlates of PNE, including socio-demographic, health and recreational drug use characteristics.

FINDINGS

The life-time prevalence of PNE was 4.0% [95% confidence interval (CI) = 3.62, 4.38], and the past-year prevalence was 2.1% (95% CI = 1.82, 2.38). Life-time pharmacological mood enhancement (3.1%; 95% CI = 2.76, 3.44) was more prevalent than pharmacological cognitive enhancement (1.4%; 95% CI = 1.17, 1.63). Fifty-four participants reported both (0.5%; 95% CI = 0.36, 0.64). PNE was associated with studying rather than full-time [odds ratio (OR) = 0.35; 95% CI = 0.21, 0.57] or part-time employment (OR = 0.39; 95% CI = 0.23, 0.67), stress (OR = 1.51 95% CI = 1.31, 1.75), cocaine (OR = 2.40; 95% CI = 1.51, 3.82) and amphetamine use (OR = 2.44; CI 95% = 1.37, 4.33), diagnosis of a mental disorder (OR = 4.26; 95% CI = 3.14, 5.80), and perceived poor health (OR = 0.76; 95% CI = 0.64, 0.90).

CONCLUSIONS

Taking prescription or recreational drugs for pharmacological neuroenhancement is rare among Swiss employees and students (4.0%). Pharmacological mood enhancement (3.1%) is more prevalent than direct pharmacological cognitive enhancement (1.4%).

The importance of stress, self-efficacy, and self-medication for pharmacological neuroenhancement among employees and students

OBJECTIVES

This study examined the relationship between stress, self-efficacy, self-medication, and pharmacological neuroenhancement (PNE) in the Swiss general population.

METHODS

Using the largest Swiss Internet panel, a sample of 10,171 employees and students (unweighted N=10,084) aged 15-74 years was recruited and asked to complete a self-administered online survey. The data were weighted for age, sex, and language region to provide results that were representative of the Swiss population. Multinomial logistic regression models were conducted to identify predictors of pharmacological cognitive enhancement (PCE) and pharmacological mood enhancement (PME) over the past year. Two self-medication models and an overall model were determined.

RESULTS

Current medical treatment for a mental disorder was the best predictor of both PCE and PME use as serious self-medication. The overall model revealed that cannabis use, frequent stress, and long-term stress were predictors of both PCE and PME, whereas negative stressors and time pressure at work did not remain in the final model. Furthermore, past-year PCE with and without PME was associated with being male, being a student, and using illegal drugs other than cannabis, whereas being female and having low self-efficacy predicted past-year PME only.

CONCLUSIONS

Consideration of the predictor variables identified in this study may help to identify the potential PCE and PME users for whom measures to prevent drug abuse and manage stress are most appropriate. More specifically, the use of PCE and PME as self-medication to enhance performance at work or while studying needs further consideration in the neuroenhancement debate.