[tt] NYT: Brain Enhancement Is Wrong, Right?

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Brain Enhancement Is Wrong, Right?
http://www.nytimes.com/2008/03/09/weekinreview/09carey.html
8.3.9
[Related material added.]

Smartening Up
By BENEDICT CAREY

SO far no one is demanding that asterisks be attached to Nobels,
Pulitzers or Lasker awards. Government agents have not been raiding
anthropology departments, riffling book bags, testing professors'
urine. And if there are illicit trainers on campuses, shady tutors
with wraparound sunglasses and ties to basement labs in Italy, no
one has exposed them.

Yet an era of doping may be looming in academia, and it has ignited
a debate about policy and ethics that in some ways echoes the
national controversy over performance enhancement accusations
against elite athletes like Barry Bonds and Roger Clemens.

In a recent commentary in the journal Nature, two Cambridge
University researchers reported that about a dozen of their
colleagues had admitted to regular use of prescription drugs like
Adderall, a stimulant, and Provigil, which promotes wakefulness, to
improve their academic performance. The former is approved to treat
attention deficit disorder, the latter narcolepsy, and both are
considered more effective, and more widely available, than the drugs
circulating in dorms a generation ago.

Letters flooded the journal, and an online debate immediately
bubbled up. The journal has been conducting its own, more rigorous
survey, and so far at least 20 respondents have said that they used
the drugs for nonmedical purposes, according to Philip Campbell, the
journal's editor in chief. The debate has also caught fire on the
Web site of The Chronicle of Higher Education, where academics and
students are sniping at one another.

But is prescription tweaking to perform on exams, or prepare
presentations and grants, really the same as injecting hormones to
chase down a home run record, or win the Tour de France?

Some argue that such use could be worse, given the potentially deep
impact on society. And the behavior of academics in particular, as
intellectual leaders, could serve as an example to others.

In his book "Our Posthuman Future: Consequences of the Biotechnology
Revolution," Francis Fukuyama raises the broader issue of
performance enhancement: "The original purpose of medicine is to
heal the sick, not turn healthy people into gods." He and others
point out that increased use of such drugs could raise the standard
of what is considered "normal" performance and widen the gap between
those who have access to the medications and those who don't -- and
even erode the relationship between struggle and the building of
character.

"Even though stimulants and other cognitive enhancers are intended
for legitimate clinical use, history predicts that greater
availability will lead to an increase in diversion, misuse and
abuse," wrote Dr. Nora Volkow, director of the National Institute on
Drug Abuse, and James Swanson of the University of California at
Irvine, in a letter to Nature. "Among high school students, abuse of
prescription medications is second only to cannabis use."

But others insist that the ethics are not so clear, and that
academic performance is different in important ways from baseball,
or cycling.

"I think the analogy with sports doping is really misleading,
because in sports it's all about competition, only about who's the
best runner or home run hitter," said Martha Farah, director of the
Center for Cognitive Neuroscience at the University of Pennsylvania.
"In academics, whether you're a student or a researcher, there is an
element of competition, but it's secondary. The main purpose is to
try to learn things, to get experience, to write papers, to do
experiments. So in that case if you can do it better because you've
got some drug on board, that would on the face of things seem like a
plus."

She and other midcareer scientists interviewed said that, as far as
they knew, very few of their colleagues used brain-boosting drugs
regularly. Many have used Provigil for jet lag, or even to stay
vertical for late events. But most agreed that the next generation
of scientists, now in graduate school and college, were more likely
to use the drugs as study aids and bring along those habits as they
moved up the ladder.

Surveys of college students have found that from 4 percent to 16
percent say they have used stimulants or other prescription drugs to
improve their academic performance -- usually getting the pills from
other students.

"Suppose you're preparing for the SAT, or going for a job interview
-- in those situations where you have to perform on that day, these
drugs will be very attractive," said Dr. Barbara Sahakian of
Cambridge, a co-author with Sharon Morein-Zamir of the recent essay
in Nature. "The desire for cognitive enhancement is very strong,
maybe stronger than for beauty, or athletic ability."

Jeffrey White, a graduate student in cell biology who has attended
several institutions, said that those numbers sounded about right.
"You can usually tell who's using them because they can be angry,
testy, hyperfocused, they don't want to be bothered," he said.

Mr. White said he did not use the drugs himself, considering them an
artificial shortcut that could set people up for problems later on.
"What happens if you're in a fast-paced surgical situation and
they're not available?" he asked. "Will you be able to function at
the same level?"

Yet such objections -- and philosophical concerns -- can vaporize
when students and junior faculty members face other questions: What
happens if I don't make the cut? What if I'm derailed by a bad test
score, or a mangled chemistry course?

One person who posted anonymously on the Chronicle of Higher
Education Web site said that a daily regimen of three 20-milligram
doses of Adderall transformed his career: "I'm not talking about
being able to work longer hours without sleep (although that
helps)," the posting said. "I'm talking about being able to take on
twice the responsibility, work twice as fast, write more
effectively, manage better, be more attentive, devise better and
more creative strategies."

Dr. Anjan Chatterjee, an associate professor of neurology at the
University of Pennsylvania who foresaw this debate in a 2004 paper,
argues that the history of cosmetic surgery -- scorned initially as
vain and unnatural but now mainstream as a form of self-improvement
-- is a guide to predicting the trajectory of cosmetic neurology, as
he calls it.

"We worship at the altar of progress, and to the demigod of choice,"
Dr. Chatterjee said. "Both are very strong undercurrents in the
culture and the way this is likely to be framed is: 'Look, we want
smart people to be as productive as possible to make everybody's
lives better. We want people performing at the max, and if that
means using these medicines, then great, then we should be free to
choose what we want as long as we're not harming someone.' I'm not
taking that position, but we have this winner-take-all culture and
that is the way it is likely to go."

People already use legal performance enhancers, he said, from
high-octane cafe Americanos to the beta-blockers taken by musicians
to ease stage fright, to antidepressants to improve mood. "So the
question with all of these things is, Is this enhancement, or a
matter of removing the cloud over our better selves?" he said.

The public backlash against brain-enhancement, if it comes, may hit
home only after the practice becomes mainstream, Dr. Chatterjee
suggested. "You can imagine a scenario in the future, when you're
applying for a job, and the employer says, 'Sure, you've got the
talent for this, but we require you to take Adderall.' Now, maybe
you do start to care about the ethical implications."

Drug Abuse in College
http://www.nytimes.com/2005/07/31/education/edlife/jacobs31.html
July 31, 2005

The Adderall Advantage
By ANDREW JACOBS

IT was finals week at Columbia University and Angela needed a
miracle. Like many of her classmates, Angela, a bleary-eyed junior,
had already pulled a pair of all-nighters to get through a paper on
"Finnegans Wake," a French test and an exam for her music humanities
class. All that remained was a Latin American literature final, but
as midnight approached, her stamina was beginning to fade. "This
week is killing me," she said, taking a cigarette break in front of
the school library. "At this point, I could use a little help."

Thanks to a friend, the tiny orange pill in her purse would provide
the needed miracle. Angela, who asked that her last name not be
published for fear of alarming her family and angering university
officials, popped a 30-milligram tablet of Adderall into her mouth,
washed it down with coffee and headed back to the library for
another night of cramming. The next morning, she sailed through the
exam confidently and scored an A. "I don't think I could keep a 3.9
average without this stuff," she said afterward.

At many colleges across the country, the ingredients for academic
success now include a steady flow of analeptics, the class of
prescription amphetamines that is used to treat attention deficit
hyperactivity disorder.

Since Ritalin abuse first hit the radar screen several years ago,
the reliance on prescription stimulants to enhance performance has
risen, becoming almost as commonplace as No-Doz, Red Bull and maybe
even caffeine. As many as 20 percent of college students have used
Ritalin or Adderall to study, write papers and take exams, according
to recent surveys focused on individual campuses. A study released
this month by the National Center on Addiction and Substance Abuse
at Columbia found that the number of teenagers who admit to abusing
prescription medications tripled from 1992 to 2003, while in the
general population such abuse had doubled.

Dr. Robert A. Winfield, director of University Health Service at the
University of Michigan, Ann Arbor, sees a growing number of students
who falsely claim to be A.D.H.D. so they can get a prescription. At
least once a week, a jittery, frightened, sleep-deprived student who
has taken too many tablets for too many days shows up at his office.
"Things have really gotten out of hand in the last four to five
years," he said. "Students have become convinced that this will help
them achieve academic success."

On campus, the drugs are either sold or given away by people with
prescriptions, or they are procured by students who have learned to
navigate the psychiatric exams offered by campus health centers,
which usually provide the drugs at a discount. Unlike Ritalin, two
newer members of the family of analeptics - Adderall and Concerta -
come in time-release forms and can keep a patient medicated an
entire day.

Much like performance-enhancing drugs in professional sports, the
spread of analeptics among college students is raising issues of
competitiveness and fairness. But interviews and e-mail exchanges
with two dozen Columbia students suggest that the prevailing ethos
is that Adderall, the drug of choice these days, is a legitimate and
even hip way to get through the rigors of a hectic academic and
social life. "The culture here actually encourages people to use
stimulants," said Barak Ben-Ezer, a computer science and economics
major who prefers Red Bull, a caffeinated beverage, and cigarettes
over prescription drugs. But pure recreational use of the drugs,
which sometimes includes crushing and snorting a tablet, is
generally frowned on, he and others said.

Libby, a writing major at Columbia who received a diagnosis of
A.D.H.D. in first grade, is a typical drug dealer. She often sells
her 10-milligram tablets to strangers for $5 or barters them with
friends for meals. The demand during exam week can get intense, said
Libby, who, like most people interviewed for this article, asked
that her last name be withheld. "I'm constantly being bombarded with
requests," she said. "People can get desperate."

She said that the attitude toward stimulants has changed drastically
since her days in elementary school, when she was forced by her
parents to down a daily regimen of Ritalin. "As a kid, I was made to
feel different for taking these drugs," she said. "Now it's almost
cool to take them."

Many mental health counselors point out that the proliferation of
analeptics on college campuses is partly a matter of demographics.
The hundreds of thousands of children who were diagnosed with
A.D.H.D. and attention deficit disorder in the early 1990's are now
entering college, and bringing their drugs with them. Libby, for
one, takes them only to pull through the occasional paper. "It
really messes with my head," she said, adding that in the past the
medication has intensified underlying obsessive-compulsive habits.

Some experts, while fretting about the use of analeptics without a
prescription, see the advent and acceptance of the drugs as a great
revolution that has helped a generation of children with learning
disabilities achieve academic success. Dr. Robert Herman, a staff
psychiatrist at the University of Maryland, College Park, says he
regularly sees students whose grade point averages rise markedly
after taking the medication. "Students tell me it's really changed
their lives for the better, that they are so much more focused and
organized," he said.

Sorting out those with legitimate diagnoses from the deceivers can
be nearly impossible, he said, because "in psychiatry, there is no
blood test." He said he always tells patients that it's illegal to
share their medicine, but added, "I can't exactly go into their dorm
room and count their pills."

Requests for comment by Columbia administrators were referred to Dr.
Laurence Greenhill, a clinical psychiatrist at the university, who
said that the idea that Adderall is a performance enhancer is a
myth. "It won't increase your intelligence, it just increases your
diligence," he said. "Essentially, the drugs delay the onset of
sleep so you can stay up all night and cram."

Designer stimulants like Adderall are far less dangerous than
cocaine or methamphetamines. According to the Shire Pharmaceuticals
Group, which makes Adderall, medical research has found it has no
potential for addiction. But Adderall, like many other medications,
can interact with other drugs and create problems, particularly when
taken in other-than-prescribed dosages, a spokesman said. The main
side effects of analeptics are increased heart rate, agitation and
the kind of paranoia and disorientation that results from
amphetamine-induced insomnia. In February, the Canadian government
suspended sales of Adderall XR, the time-release version of the
medication, noting "20 international reports" of sudden deaths,
heart-related deaths and strokes in children and adults. (The
standard Adderall is not sold in Canada.) In Washington, the Food
and Drug Administration took note of the Canadian ban but said it
would take no action.

"These are very safe medications," said Timothy E. Wilens, author of
"Straight Talk About Psychiatric Medications for Kids" and a child
psychiatrist at Harvard Medical School. "They have been used for 70
years, and we haven't had terrible catastrophes."

For many college students, the issue about Adderall is not so much
health as it is fairness. Among those who refuse to dabble in
performance-enhancing substances, the disapproval and bitterness can
be fierce. Angelica Gonzales, a civil engineering major at Columbia,
said she resented that nearly all her friends have taken Adderall at
some point in their academic careers. "It's cheating, and it really
bothers me," she said, a bundle of notes in her lap. "I mean,
everyone here is smart. They should be able to get by without the
extra help."

The more popular sentiment about Adderall's role in academic success
was explained by John, an economics major who was raised in a
conservative Midwestern culture. He said he always believed that if
you had trouble in school, you should just study harder. But since
coming to Columbia three years ago, his thinking has changed. "The
environment here is incredibly competitive," he said. "If you don't
take them, you'll be at a disadvantage to everyone else." With that,
he swallowed a 20-milligram tablet of Adderall and headed back into
the library.

Andrew Jacobs is a reporter for The Times.

Would you boost your brain power? from Nature News and Opinion forum on 
Nature Network
http://network.nature.com/forums/naturenewsandopinion/816

Would you boost your brain power?
Sarah Tomlin
Wednesday, 12 December 2007 18:35 UTC

UPDATE JAN 31ST: This week, Nature is publishing two pages of
correspondence responding to the Sahakian and Morein-Zamir
Commentary. We're also launching an anonymous online survey to build
on the informal questionnaire that the Commentary authors sent to
academics on the usage of brain boosting drugs. In aggregate, the
survey results will guide future editorial content on this topic.
Check back here for more updates.*

Two scientists writing a commentary article in the December 20 issue
of Nature want to stimulate your brains - in more ways than one.

Barbara Sahakian and Sharon Morein-Zamir from the Department of
Psychiatry at Cambridge University argue that the increased usage of
brain-boosting drugs by ill and healthy individuals raises ethical
questions that cannot be ignored. An informal questionnaire Sahakian
and Morein-Zamir sent to some of their scientific colleagues in the
US and UK revealed fairly casual use by academics, and we now want
to hear your views on the topic..

The authors arguments can be read in more detail here. An earlier
Nature editorial also discussed some of the ethical issues
surrounding drug-based enhancement in healthy individuals inspired
by a longer discussion paper from the British Medical Association.

To trigger broader discussion of these issues Sahakian and
Morein-Zamir propose the following questions:

> Should adults with severe memory and concentration problems be
given cognitive enhancing drugs?

> If such drugs have only mild side effects, should they be
prescribed more widely for other psychiatric disorders?

> Do the same arguments apply for young children and adolescents
with neuropsychiatric disorders, such as those suffering from ADHD?

> Would you boost your own brain power?

> How would you react if you knew your colleagues - or your students
- were taking cognitive enhancers?

> How should society react?

Please contribute to this online discussion. We especially want to
hear from you if you're already using these drugs - or if you know
people who are. What are your reasons for taking, or not taking,
these drugs?

For the next two weeks the authors of the Nature commentary will be
joining in the conversation here. Barbara Sahakian also discusses
cognitive enchancers on Nature's podcast, extract posted here

Get ready to expand your mind..

Updated 30 January 2008 18:46 UTC


Jeffrey White
19 December 2007 | 22:46
I think that the last three questions are the most
interesting, so my reply will focus on these issues.
I have and will continue to boost my own brain power to
achieve an analeptic effect. CNS stimulants include a
diverse array of comonly used drugs, such as theophylline
(tea), caffeine (coffee, soft drinks, NoDOz, etc.) and even
nicotine. I do drink both coffee and tea. I do not think
however that these encompass an unfair boost in brain
power. Moreover, I think that most will agree with that
claim since these products can only be used as an
analeptic.
The issue arises when more efficacious compounds that have
an effect on cognitive power, rather than wakefulness, are
considered. I have not and would not use a compound, such
as methylphenidate, to increase my brain power. As
mentioned in the article, some persons do need this to
function on a normal level. I guess that I am lucky that I
do not.
I interact daily with those people who choose to take
drugs, such as methylphenidate and modafinil, to study
better. When I was in classes with these people, it was
easy to distinguish them: their constant bitter attitude
and short temper were just a couple of the signs. I think
that their motivation for abusing these drugs is to perform
well on examinations. This attitude permeates the academic
sectors of U.S. education and is an entirely different
discussion. I used the term abuse because, to me, this is
an abuse of their intended effects. I would assume that the
chronic abuse of these substances would produce tolerance
and, eventually, would create a physical dependence. This
is only speculation.
I think that people should be able to take these substances
if they so desire since, at least currently, there are no
safety restrictions. Personally, I do not take these
substances because I am able to perform well on
examinations with ample studying and preparation. I think
that it is unfortunate, however, that some of my colleagues
will depend on these substances to perform well in their
future professions. As a MD/PhD student, I do not think
that a physician nor a research scientist should have to
rely on an exogenous substance for their mental creativity
and performance on the job. Therefore, though I think that
people should be able to make their own choices, I will be
bold enough to predict that, at some point, these
substances will be federally regulated to prevent abuse.
Unfortunately, I do not think that this will occur until
some mishap, either on the operating table or in a
loboratory, first occurs.
I hope that I have not offended anyone with my comments. I
realize that some individuals do require these substances
to function normally and I am sensitive to those needs.
+

Peter Reiner
20 December 2007 | 00:19
Sahakian & Morein-Zamir in their Commentary "Professor's
little helper" have done a wonderful job of instigating
debate on the topic the ethical issues associated with the
emergence of cognitive enhancers. I would view the final
question, "How should society react?", as the most
important of all. The full response is far from
straightforward, and will occupy us for some time to come,
but at least a significant part of the answer to this
question can be summarized with one word: honesty.
With cognitive enhancement already well-established, be it
the mild pharmacological boost that comes from a cup of
coffee or stronger medicines that are on the doorstep, a
range of issues will require serious discussion. Foremost
on the regulatory side will be the labeling of new drugs.
If the past is any indication, one likely scenario is that
the drugs will be developed for a particular disease
indication and then off-label use will expand penetration
into the general population at large. This 'wink and nod'
to acceptance of wider distribution is unwise, as it
provides little opportunity to assess risks in, or give
appropriate counsel to the general population that
inevitably will be taking the drugs. A much healthier
approach would be to accept the fact that cognitive
enhancers will be widely utilized, define populations of
individuals in which they can and will be used, carry out
appropriate studies to assess not only issues of safety but
also of social impact, and use these results to inform the
labeling of the drugs. By adopting such an honest approach
to this new frontier of neuropharmacology, we will be in a
stronger position to grapple with the tangle of thorny
issues that are certain to arise.
+

Sarah Tomlin
20 December 2007 | 11:58
Posted on behalf of Judy Illes: Wednesday, 19 December 2007
23:18 UTC
The "Professor's little helper" on cognitive enhancement by
Barbara Sahakian and Sharon Morein-Zamir demonstrates the
enduring nature of this topic. With their comments in hand,
it is now time to explore the range of new issues
implicated by their reflections. In particular, the legal
and social policies that will guide the setting of
parameters and milestones for integrating new enhancing
technologies into health care for treatment, and into
society for non-therapeutic applications, must be at the
heart of the discussion. Policy-making is inherently
complex, and is rendered even more complex when the
priorities of different health care systems come into play,
and the commercial interests of big business pharma - and
eventually big business "bio-device" - inevitably influence
those priorities. Moreover, it is certain that there will
be no one-size-fits-all policies once multiculturalism is
taken into consideration. Beyond the call that the authors
make for better drugs, our call is for a next generation of
research and translation that is focused on regulatory
policies - policies that recognize the differential impact
of drugs on different segments of society, and policies
that protect people from the urge for quick fixes and the
risk of new forms of vulnerabilities arising from
short-sighted solutions.
Robin Pierce, J.D., Ph.D. Judy Illes, Ph.D. National Core
for Neuroethics The University of British Columbia
+

Trevor Liberson
20 December 2007 | 12:10
First let me declare an interest in this discussion. As a
student of seventy-nine years of age, having recently
gained a BSc in biosciences and being at the end of an MRes
in biotechnology I view the approach of any sort of
neurodegenerative disease with more than a little
apprehension. I must congratulate Sahakian & Morein-Zamir
on their clear and rational approach to a subject that must
be of increasing importance to society as a whole.
While the abuse of any drug is to be discouraged, the
definition of that abuse can vary in different sections of
the population; a desperate student may or may not be
abusing modafinil in the days before an examination. A
desperate soldier with an enemy in hot pursuit is certainly
not, and probably wouldn't care if he was.
The staggering cost of dementia, which must increase as the
demographic gap increases and medical treatment and
survival rates improve can only be described as horrifying,
and the chance of a 1% improvement would seem to be an
offer that we can't refuse.
This is not a case of the use of drugs to enhance the
financial status of the individual. The cost of maintaining
an elderly population represents a crushing and unfair
burden on the young, which in its own way is as important
as climate change and should be given an equal position of
importance.
Having witnessed degeneration and loss of faculties in
friends and family members, the fact that drugs exist which
can ameliorate if not cure these effects, indicates to me
that these drugs should always be used in the cases where
the side effects can be tolerated.
Incidentally, I've never used cognitive enhancing drugs
myself.
Trevor Liberson.
+

Sharon Morein
20 December 2007 | 12:21
I've seen that some people on blogs who require cognitive
enhancing drugs due to some medical condition use them
grudgingly. On the one hand they say they really do help,
but on the other they resent the drug turning into a
crutch. One even admitted to taking a bit 'extra' on days
when she needed the edge. What does this suggest about
healthy individuals developing a dependence on such drugs?
Once you know that taking it will allow you to go the extra
mile, is there a danger of wanting to take it at the onset
of every challenging day?
+

henry greely
20 December 2007 | 12:46
This excellent article covers the territory well, but I am
left with a question about our current policy and our
current drugs.
What do we know about long-term, regular use of modafinil?
Do we have any useful studies of the differences, if any,
in the drug's effects (good and bad) between occasional
users (for jet lag, let's say)and regular users (four or
five days a week)?
I ask because the benefits of modafinil seem too weak to
justify serious social concerns about fairness or coercion,
so that only the safety issues seem pertinent. If we do not
have long term safety studies, we might want to consider a
regime that continues to require a prescription (or other
form of professional intermediation but that limits the
amount of the drug that can be obtained at any one time.
If we do and extended use seems reasonably safe (however
that is defined) and if we know of no significant drug
interactions, it is not clear to me that continuing
professional involvement is necessary. If there are
significant drug interactions, professional review may
still not be required if other methods of cross-checking
for interactions are created.
So I think one interesting side effect of this discussion
of cognitive enhancement is that it shines a light on
possible changes in prescription requirements -
specifically the possible creation of a category of
substances somewhere between "over-the-counter" and full
prescription. Of course, the justification for such a move
depends on the specific facts known about the drug.
Ultimately, though, if modafinil is, in its safety profile,
like tasteless, odorless (and calorie-less, for those who
otherwise use milk and sugar) coffee, it seems hard to
argue for special controls. More powerful drugs, that are
better enhancers or have more dangerous effects, may, as
you point, require regulation for reasons other than
safety.
I would raise one other point, minor but perhaps
interesting, point to consider - there are some religions
that might have objections to modafinil or other
stimulating drugs. I am thinking particularly of the
Mormons (formally the Church of Jesus Christ of the Latter
Day Saints). They ban the use of caffeine and presumably
might well consider at least non-medical uses of modafinil
as being equivalent. Would any regulatory scheme for
modafinil, or other stimulants, need to make special
provision ("conscience clauses"?) for those with religious
objections?
+

Alfredo Pereira Jr
21 December 2007 | 02:53
Besides ethical issues, neuropharmacological complexities
should be taken into account in this discussion. Supplying
the brain with precursors of transmitters causes dependence
and reduces endogenous production. Reducing transmiter
uptake is more benign but may have corollary effects. Drugs
that block or enhance ionotropic receptors activity have
dose-dependent effects and do not cause dependence. Drugs
that increase transmitter or membrane receptor production,
or that increase production of a protein that controls the
location of receptors in the post-synapic density, may have
unpredicted effects.
Brain complexity requires an epistemological discussion of
neuropharmacology. For instance, reducing inhibitory
activity (e.g. inhibiting GABAergic inhibitory
transmission) is not the same as increasing excitatory
activity (e.g. increasing glutamatergic transmission), but
in practice the effects may look the same. Normal brain
functionning depends on a balance of excitation and
inhibition, but the effects of inhibition are still not
well understood. Is inhibition just conterbalancing
excitation, or does it also have a constructive role? How
does inhibition impact on the EEG and BOLD fMRI? These
techniques do not identify the contribution of excitatory
and inhibitory activity to the generation of (respectively)
electric fields (EEG) or hemodynamic responses (fMRI).
Until there is a better understanding of inhibition, and
the roles of the balance of excitation and inhibition, it
is difficult to predict the long-lasting effect of drugs
that interfere with these processes.
+

peter freer
21 December 2007 | 15:09
Frankly, I think the article is misleading and provides a
bit of misinformation regarding cognitive enhnacement.
Before even exploring ethical issues, one has to understand
the facts about 'cognitive enhancement'. The facts don't
necessarily reflect what the authors present in the
article. I'd review them before debating the ethics of a
Ritalin mist as I walk into the classroom.
The longest study performed on stimulant medication & ADHD
was the MTA (Multi-modal Treatment Study of Children with
ADHD. A three year observation and assessment of medication
compared to behavioral therapy was performed by various
'experts' under the National Institutes of Mental Health
(USA). At the end of 36 months:
o There were no significant performance differences
between groups that had been medicated and groups that
did nothing (no intervention) at all.
o No global academic improvement
o No behavioral improvement
o No social skill improvement
o Increased weight loss among the medication group
o Stunted growth among the medication group
Co-author, Professor William Pelham, of the University at
Buffalo, says: "The children had a substantial decrease in
their rate of growth so they weren't growing as much as
other kids both in terms of their height and in terms of
their weight. And the second was that there were no
beneficial effects - none."
Here's the most telling observation of the study: "I think
that we exaggerated the beneficial impact of medication in
the first study. We had thought that children medicated
longer would have better outcomes. That didn't happen to be
the case. There's no indication that medication's better
than nothing in the long run."
The students did demonstrate academic improvement, but only
for a short duration.
Finally, the Drug Effectiveness Review Project, based at
Oregon State University released a 731-page report which
thoroughly analyzed 2,287 studies - virtually every
investigation ever done on ADHD drugs anywhere in the world
- to reach its conclusions. To date, it is the most
thorough and comprehensive evaluation of all research
performed on ADHD drugs.
In its analysis of published and unpublished research data
produced by six prominent ADHD medication producers, the
group found that 2,107 studies were unreliable and were
subsequently rejected. Now, this is telling in itself.
Finding 2,107 funded yet critically poor or fundamentally
flawed studies performed by universities and the
pharmaceutical industry itself speaks volumes to the nature
of that research and those people responsible for it.
The Project began its review of the remaining 180 studies
which demonstrated good controls and methods. Its
conclusions regarding ADHD medication were quite
astounding.
Here, bulleted, are some incredible results with comments:
o "No evidence on long-term safety of drugs used to treat
ADHD in young children" or adolescents. Now, if you ask any
physician, or the pharmaceutical industry, they will tell
you the drugs are completely safe for long-term use based
on research. That research doesn't exist.
o The research providing any evidence of safety is of "poor
quality." This includes research regarding the possibility
that some ADHD drugs could cause heart or liver conditions,
tics, or stunt growth.
o "Good quality evidence ... is lacking" that ADHD drugs
demonstrate improvement in "global academic performance,
consequences of risky behaviors, social achievements," and
other measures. The common perception is that ADHD drugs do
improve academic performance and social skills. Many drug
makers use ads depicting this. However, evidence for
long-term improvement in academics, social skills, or
behavior is virtually non-existent.
o Drug makers have found that they can expand their market
by inducing adults into the ADHD experience. However, the
Project found that evidence "is not compelling"
demonstrating that ADHD drugs actually help adults, nor is
there evidence that one drug "is more tolerable than
another."
Furthermore, the Project found that the U.S. Food and Drug
Administration doesn't require pharmaceutical manufacturers
to compare newly developed medications with medications
currently on the shelf. Most companies simply use a placebo
or sugar pill given instead of their medication as a
control. Therefore the Project found that "good quality"
studies are lacking that pit one drug against another to
provide evidence of effectiveness. It also could not find
comparative data which might help determine which ADHD
medications are less likely to produce detrimental side
effects like heart and liver problems, depression,
decreased appetite, tics, or seizures.
The Project could not find research that clearly provided
an understanding of way that ADHD drugs work. It is not
well understood for most ADHD drugs. If ADHD stimulants
affect neurotransmitters as doctors Barbara Sahakian and
Sharon Morein-Zamir suggest, this is pure speculation.
+

Brendan Maher
21 December 2007 | 15:11
But will they put asterisks next to their Nobels?
I'm quite pleased to see that neuroscience and ethics blogs
all over the place have been picking up this discussion. I
posed to a number of them, a question that seems quite
simple on the face of it. If a drug could make you smarter,
without any negative side effects, would you take it? If
you can take away the risk of personal harm (granted, a
pretty tall order), it becomes largely an argument of
fairness. Is it cheating? When Barry Bonds broke the home
run record, many suggested that an asterisk be placed next
to the new record indicating that Bonds had taken
performance enhancing drugs. Is it the same with brain
boosters? The discussions on these blogs have been
particularly active. I can't say that I'm surprised.
Shelley Batts at Retrospectacle doesn't think so:
"...it is difficult to argue that taking a cognitive
enhancer is cheating in the academic sense, since a pill
will never inform you as to the correct answer on a
multiple choice test or give you the answer to any essay
question. It will only improve the focus and grasp on
information which you already know."
Janet Stemwedel at Adventures in Ethics and Science takes
more of a purist's approach saying she wants ownership over
her faculties. Then again those who need the drug for
medical reasons oughtn't be penalized in any way.
"Honestly, I'm conflicted about this attitude of mine
towards the products of thinking with my "natural" brain. I
don't think the work of my colleagues who take medications
for their depression or ADHD or anxiety is any less their
work."
Dave Munger at the ever popular Cognitive Daily gave a
personal narrative of a situation where using such drugs
seems right. And he brings up a slippery slope argument
that is worth debating, although it does tend to veer a bit
Vonnegut (which isn't a bad thing for a discussion to do).
"Ultimately, even if we could create drugs that were truly
side-effect free, I think we'd still have to regulate them
in order to protect us from ourselves. Just as the
regulation of steroids in athletics is done mainly to
protect the athletes, so even "perfect" cognitive enhancers
will need to be restricted in their use, lest we become of
planet of work-immersed zombies."
To which one commenter responds:
"Why do you assume we would use cognitive enhancement to do
more work, especially the kind of work we don't enjoy? If I
had a drug that cut my sleeptime by half, I'd use the extra
time to enjoy myself. If I had a drug that helped me think
better or faster, I'd finish my daily work more quickly and
so work less, not more."
Probably a coincidence, but Jonathan Eisen on the Tree of
Life "confesses" to using cortisone to recover from an
injury, and wonders if that's cheating.
"Is using steroids to recover from an injury OK (see Andy
Pettite). What if I got the steroids to make my typing
faster. Would that be cheating?"
If you see good posts around the internet on this, please
share them.
+

steven rose
21 December 2007 | 19:52
Sahakian and Morein-Zamir reprise many of the arguments
over cognitive enhancers that have become familiar in
recent years. I however want to raise three issues from the
more neuroscientific to the more practical. First, we need
to be clearer about what is meant by the term 'cognitive
enhancer.' Cognition is not a unitary phenomenon, but
involves many different processes. The suggestion by
Giurgia, who invented the term back in the '70s that there
might be a drug that could function as a 'pure' nootropic
agent is almost certainly a fantasy. To take some of
Sahakian and Morein-Zamir's examples, methylphenidate is
supposed to enhance attentiveness, thereby enabling pupils
to focus better on their school work, Modafanil increases
alertness over long periods, which is why it was said to
have been used by US pilots during their bombing raids over
Iraq. The current generation of cholinergic drugs used to
treat early stage Alzheimer's have a whole range of central
and peripheral effects, but were developed to treat memory
failure, based on the hypothesis that memory formation
(though not retrieval) involves cholinergic neurons -
though this may not actually explain their limited
efficacy. Drugs designed to treat the specific biochemical
lesions in Alzheimer's may not work in other forms of
cognitive decline, or to 'enhance' normal memory or
cognition where the biochemical systems are more or less
optimally set. There are thus many pharmacological ways,
via many different neural processes, in which 'cognition'
can be affected.
The second issue is whether there is anything different in
principle between 'enhancing' school or other intellectual
performance by taking a drug or by extra coaching or being
brought up in a supportive educational household. To argue
that there is a fundamental distinction is to be implicitly
Cartesian. It is to presume that coaching and an
educationally supportive environment don't change brain
processes - or that if they do, this is a more legitimate
way of changing those processes than by direct chemical or
physical intervention. But if they don't, how are they
supposed to work? The argument, as everyone recognises, is
by analogy with the use of drugs in athletics, which is
seen as cheating, whereas changing one's metabolism by
training or by the fortune of genetics, is uncontroversial.
The fact that it is difficult to draw an in principle
distinction between coaching or training and popping a pill
doesn't alter the equally important fact that most people
regard the former as acceptable and the latter as cheating
- or 'achieving a competitive advantage,' as the advocates
of using smart drugs describe it.
The practical question however is whether in any event it
is possible to regulate or control the use of performance
enhancers. Drug policy in athletics is a mess, with a sort
of continuous arms race between the athletes and the
authorities, and I suspect that in the case of 'cognition'
the situation would be even worse. Banned drugs are
obtainable readily over the net, and no-one is ever going
to ban taking coffee before going into an exam. I have
recently been working with a young person's theatre group,
who have been touring a play ('Mind the Gap') raising some
of these issues for school students. Asked before and after
seeing the play whether they would take 'smart drugs,' most
said no on the grounds that it would be cheating. But if
they thought their fellow students were taking drugs, they
would too. Of course, as any putative cognitive enhancer,
like any other powerful drug, is likely to have adverse or
unwanted effects associated with it, what is needed,
especially for young users, is decent (but non-directive)
education on drug effects rather than attempt coercion.
One final point should not go unaddressed. Sahakian and
Morein-Zamir's reference to ADHD as heritable and affecting
4-10% of children world-wide is, to put it no more
strongly, contentious. The claimed incidence of ADHD varies
dramatically over time (less than 0.1% in the UK before
1990, now generally claimed, even by its advocates, to be
between 1-5%) and country (highest in the US, followed by
Australia and I believe Iceland, low in Italy for
instance). The diagnosis is in many cases questionable and
evidence on heritability shaky except in highly selected
groups. The dramatic increase in the prescription of
Ritalin (methylphenidate) - from 2000 a year in 1991 to
over 300,000 in the UK today says more about fashions in
diagnosis and treatment of naughty or inattentive or
badly-parented children than it does about a genuinely
heritable 'disease.' In the US the FDA has called attention
to the 'epidemic' of schoolyard Ritalin use. As Sahakian
and Morein-Zamir say, there is disturbing evidence of
long-term adverse sequelae of the use of such
amphetamine-like drugs especially for young and developing
brains. But whilst the assumption behind the cognitive
enhancer debate is that users are essentially making free
choices about whether or not to take the risks, children
being prescribed Ritalin are not autonomous agents; they
are being drugged as a method of social control.
That, it seems to me, is a real ethical issue. But if we
don't recognise the real world situation in which drugs are
bought, prescribed and used, then the ethical debate is
vacuous.
Steven Rose
[There are more.]

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