As drugs for cognitive disorders improve, so does the temptation to use them even when one does not have a cognitive disorder?

How Smart Are We About Smart Drugs? Using ‘brain’ pills to improve on normal leads to new questions of ethics As drugs for cognitive disorders improve, so does the temptation—or the opportunity—to use them even when one does not have a cognitive disorder. Should we worry when we hear that thousands of presumably healthy college students take only-by-prescription drugs such as Ritalin and Adderall to improve their concentration? What if they are taking “dietary supplements,” such as energy drinks or pills? What if they are drinking a lot of coffee? What if they are doing these things just before a major exam? What if they are doing these things before a driving test? Similar to the anabolic steroids debate in sports, people should be talking about the ethics of taking drugs to enhance mental performance, suggested a panel of neuroethicists during a forum at the Dana Center in Washington, DC, on May 14. Unlike steroids, which mainly affect the body, cognitive treatments/enhancers affect specifically the brain—its thinking, its feeling, its ability to make decisions and act on them. “We are, on the one hand, very comfortable with enhancements such as piano lessons, SAT tutoring, special coaches, which are not pharmacologic yet which are very much unevenly distributed in our society, and are ways in with the advantaged can obtain more advantage,” said Steve Hyman, provost of Harvard University. “Yet somehow, when we shift to consideration of the use of pharmacologic agents, as opposed to behavioral and other measures, the discussion takes on a very, very different tone. A very worried tone.” Part of that worry may be warranted, Hyman said. “With a free spirit and little guidance,” he said, our college kids are ingesting these drugs now. From 5 percent to 25 percent of U.S. college students (depending on the campus) say they have taken such only-by-prescription drugs as Ritalin and Adderall to improve their concentration, said Martha Farah, a professor at the Center for Cognitive Neuroscience at the University of Pennsylvania. These drugs were approved by the Food and Drug Administration because they were shown to be safe and to be effective in improving concentration in people who have troubles such as attention deficit disorder. They were never shown to be safe and effective in improving concentration in people who do not have concentration problems; they may or may not be. “It’s troubling that we know so little about the effect of these drugs on normal people, both from the health point of view and from the cognition point of view,” said Farah. Also, the drugs may affect different people in vastly different ways. “There is some reason to think that it would be very helpful to some people, and not at all helpful—and possibly deleterious—to others, in terms of cognitive performance,” Farah said, based on her testing of a milder stimulant on college students. “So before you call up your friendly doctor and get Adderall for your kid to take for their SATs, you should consider: They could be the part of the group that goes up [in skills] but they could also be the part that goes down.” Great potential There are at least 40 drugs in development as cognitive enhancement agents, said Barbara Sahakian, professor at the University of Cambridge School of Clinical Medicine. “We have all these agents coming on-line and we’ll have to decide how we want to use them.” “It’s a fantastic opportunity that we have here to help people who have either brain injuries or … neuropsychiatric disorders, some of them very disabling—they can’t work, they don’t have a good quality of life, and so forth. “We’re well-placed to help people. But of course, if it occurs that we find these new cognitive-enhancing agents, the temptation is for the general public to take advantage of these as well.” There also may be pressure on those who may not wish to take stimulants to take them, just to keep up with fellow students or with the rest of the people in the workplace. Or in the field: DARPA and other military agencies are spending hundreds of millions of dollars on finding ways to keep soldiers awake for two and three days straight, said Turhan Canli, associate professor at the State University of New York at Stony Brook. Should soldiers be forced to take such drugs? “We might need a ‘neuro-nondiscrimination’ act the way we have a genetic nondiscrimination act” to protect from such coercion, said Judy Illes, professor of pediatrics and director of the Neuroethics Imaging Program at the Center for Biomedical Ethics at Stanford University. Caveat emptor And what exactly is in those over-the-counter nutritional supplements with labels that say they will “improve focus” and help us fit more into our days? It’s hard to be sure, because they are not considered drugs and so no agency requires that they prove they are either safe or effective, said Hank Greely, professor of law and of genetics at Stanford University. As a supplement marketer, “you can’t say ‘will help Alzheimer’s’ but you can say ‘improves the memory system,’ and suddenly without any proof in advance that it’s either safe or effective, it’s legal and out there,” Greely said. “The other thing about dietary supplements is they are less regulated than children’s furniture, so there’s not only the question of whether they are safe and effective but if you buy 2 bottles of melatonin or shark cartilage at the GNC, they may have no chemicals in common,” Hyman said. Discussion needed Hyman is the president of the year-old Neuroethics Society; he and the other five speakers comprise the executive committee of the society, an interdisciplinary group of professionals interested in the many implications of advances in neuroscience. (Hyman is also a member of the Dana Foundation board of directors.) The society’s goal, beyond having a first formal meeting of the full membership next year, will be “to try to create a forum to elevate the discussion of diverse topics at the intersection between neuroscience and ethics and public policy to a broad national discussion, which we think is very, very much in need,” he said.

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