With the high availability of so-called “cognitive enhancing drugs” like Ritalin, Adderall, and Provigil on college campuses, students everywhere are facing the choice of whether or not to take non-prescribed medications to help them “perform better” in school. Studies show that anywhere between 20-35% of college students have used one of these medications without a prescription in their college career, but an informal survey would likely reveal an even higher percentage, as the use of these medications is on the rise.  Many claim these drugs help them concentrate, study longer, and juggle more tasks by creating more productive hours in the day.  Others rely on them in a crunch, during midterms, finals, or the night before a big test, when the clock is ticking and assignments are due, and there doesn’t seem to be enough time –or brain power–to get everything that needs to get done, done.

The question of whether to use these “cognitive enhancing drugs” poses many ethical concerns– some rooted in the very immediate and direct impact of these drugs on the developing brains of young people, and some rooted more in what these drugs say philosophically about the direction our society is headed in.  And with the rate of use tripling within the past ten years, along with the fact that dozens of new cognitive stimulants are currently in the pharmaceutical pipeline, it seems an important issue to examine.  Should we embrace the use of these drugs, in hopes of them making us smarter, more efficient, and more productive?  Or should we be wary of using them, concerned with the risks that they pose not only to our brains, but to our own personal and societal values?

I think before launching into the ethical arguments surrounding the use of these medications, it’s important to consider the context within which they are used, particularly on college campuses. Why do students feel compelled to take these stimulants, and why has there been such a boom in their use? What kind of environment fuels the perceived need for these medications, originally developed for disorders of attention, but now so widely used by the general public?

One idea to consider is the general trend our society is taking towards having attentional problems across the board.   Cognitive stimulants like Adderall and Ritalin were originally developed to treat Attention Hyperactivity Disorder, a disorder characterized in part by inattentivity, distractibility, and trouble staying focused; but in our era of technological multi-tasking, where everyone’s attention seems strained, are we all suffering from an attention deficit?

In his article “In Defense of Distraction,” Sam Anderson suggests we are experiencing a “crisis of attention”: and that “A quintessentially Western solution to the attention problem—one that neatly circumvents the issue of willpower—is to simply dope our brains into focus.”

Yet, no one needs an article or even an official decree from a psychologist to identify our deteriorating attention spans.  Just look around: most of us can hardly sit for any sustained period of time without checking our cell phones and our e-mail; we like things to be fast, and when they aren’t, we get frustrated. We expect instant communication and instant feedback; we even start getting antsy a few minutes into that YouTube video.  Our technologies have conditioned us to expect small bits of information, in quick surges, whether it be through Twitter, Facebook status updates, or one or two-sentence e-mail responses quickly transcribed on a Blackberry or iPhone. Even our news is increasingly transmitted in these small, quick packages. Across the board, technology is making things quicker and faster, causing us to spend less attention on each individual thing as we try to spend our attention on more things.

Indeed, we are currently experiencing an explosion of information in today’s “information age” where our cognitive loads are being challenged more than they ever have before.  Could this be said to drive the need for these medications? Just consider what an average student might be doing while trying to study: surfing the internet, checking e-mail, text-messaging, breezing through Facebook updates, listening to music, checking out a YouTube video and (let’s not forget) trying to study. With all of these inputs vying for our attention, with so much information to master, is it any wonder that we have a hard time staying focused?

Other factors surely contribute to this trend: the need for stimulants likely also stems from the immense amount of pressure students feel to get their work completed, in a time when school is more and more competitive, people are more high achieving, and there seems so much to do, and not enough time to do it in. Overwhelmed with school projects, balancing a social life, and the pressure to memorize all those Biology terms by your midterm can be daunting– sometimes, it might even seem impossible to get by without a little bit of help.  A student from a medical school chat forum went as far as to say it’s impossible to juggle school these days without the help of these drugs and live a normal life:

“The only people who get through the (med school) program I’m in either use stimulants or have no social life whatsoever. There is no other way. This is just the natural outcome of students being expected to memorize everything. The choice we’re being given is use drugs or fail.”

The pressure to juggle all of this academic pressure is certainly one driving force in the use of these drugs; but other students may use the medications less as a way to be a top, high-achieving student and more as a way to manage the day to day life of being in college, doing, well, everything college students do. In her article “Brain Gain” for The New Yorker Margaret Talbot interviewed a Harvard student with the pseudonym Alex, who said:

“I don’t think people who take Adderall are aiming to be the top person in the class…At the most basic level, they aim to do better than they would have otherwise.” He went on, “Everyone is aware of the fact that if you were up at 3 A.M. writing this paper it isn’t going to be as good as it could have been. The fact that you were partying all weekend, or spent the last week being high, watching ‘Lost’—that’s going to take a toll.”

Another student from the medical school chat forum chimed in,

“People use these medications because they’re lazy, and because they have no study habits. They’re a crutch for people who need a last minute way to get work done, fast.”

These examples seem to represent poles of a spectrum of students who take these medications – those who are seeking a high level of achievement and competitive edge, and those who are scrambling to get their papers done after slacking off all quarter – and of course, there is everyone in between, looking for a brain boost and a quick-fix way to get some help getting their work done.  In each case, the medication seems to offer a way of helping the student’s manage their workloads – including school, extra-curriculars, and even our attention-straining technologies – by giving them the opportunity to cram more work into their day.  But regardless of the reason, it is clear from the demand for these medications that there are people increasingly looking for ways to keep up – to pay attention, to stay on top, or even just to keep afloat.  And so the question one might ask, from an ethical perspective, is: “If there is a medication out there that might make it a little bit more manageable, why not take it?”

There are a number of arguments to consider when trying to address this question:

Are stimulants a tool for achievement?

In the scientific journal Nature in 2008, Director of The Center for Law and Biosciences at Stanford University Henry Greely and his colleagues published an article entitled, “Towards The Responsible Use of Cognitive Enhancing Drugs by the Healthy,” promoting the view that using medications like Ritalin and Adderall would allow us to become more focused, productive, and attentive, and that we should therefore embrace their use, not for people suffering from ADHD but for anyone who is looking for a cognitive kick.

“We should welcome new methods of improving brain function,” Greely wrote.  “In a world in which human work spans and life spans are increasing, cognitive enhancement tools – including the pharmacological—will be increasingly useful for improved quality of life and extended work-productivity, as well as to stave off normal and pathological age-related cognitive declines.  Safe and effective cognitive enhancers will benefit both the individual and society.”

“Why would you want an upper limit on the intellectual capabilities of a human being?” Nicholas Selzter, interviewed in Margaret Talbot’s article, adds.  “Think about the complexity of the intellectual tasks that people need to accomplish today.  If we had a tool to enable more people to understand the world at a greater level of sophistication, how can we prejudice ourselves against the notion?”

Indeed, some studies have demonstrated the benefits these drugs can provide.  Yesavage et al showed that pilots performed better during a month long trial of 5 mg of donepezil (Aricept, a stimulant) in flight simulation tasks, particularly in responding to emergencies. Other studies have shown that these drugs can, in some cases, help people learn better: “Amphetamines in small doses can promote neural plasticity and accelerate motor learning,” notes  Anjan Chatterjee, in his article “Cosmetic Neurology” and other stimulants have been shown to increase performance on memory and learning tasks.  Chatterjee poses the question, “Could they be used in normal subjects at the time of skilled motor learning, such as swimming, playing piano, or skiing, to increase learning potential?”

When Hank Greely presented his argument at Santa Clara last year, he put forth the idea that these drugs should be viewed as “tools” that can help people perform better, much like other tools we use to think better, for example, like a computer can serve as an instrument to help execute tasks more readily and efficiently and eyeglasses can help people see better. Some external tool that provides a leg up in studying, he says, is not much different from a medication that does the same thing; and if both can help us think, memorize, and perform better, than why close off the option of Ritalin just because it’s a “drug”?

“No one gets very worried if I enhance my eyesight by using binoculars, or if I enhance my memory using writing,” he said. “We don’t worry about “Google” as somehow an inappropriate enhancement.  We get more worried when we are changing our bodies and our changing our brains, but I’m not really sure we should be.  No one gets bent out of shape about the idea that people are using reading glasses as an evil enhancement because they are a tool.”

Greely suggests that we condone other types of “neural enhancement” with no moral problem. He writes, “research has identified beneficial neural changes engendered by exercise, nutrition, and sleep as well as instruction and reading…. cognitive enhancement drugs seem morally equivalent to other, more familiar enhancements.”

And later, puts forth the question directly: “Given the many cognitive-enhancing tools we accept already, from writing to laptop computers, why draw the line here (at giving medication), and say, thus far but no further?”

Greely’s argument essentially asks us to consider, why should influencing the brain directly using medication be considered different from using other external aids to help you study?

I think the argument is an interesting one, for it asks us to determine which technologies we consider appropriate to use to help us be more efficient and productive, and which ones we don’t.  Are we to view cognitive enhancing drugs merely as a tool that aids with a task like focus or memorization in the same way a tutor or making flashcards can help us memorize information?  And if these medications are merely a tool, should they be allowed in the same way students are permitted to use other types of study aids?  Should students come to rely on these medications with the same familiarity and comfort level that they rely on using a calculator on a math test?  Should they then be readily available to all students who want to use them?

His argument also raises the question, Why do we accept some forms of enhancement and not others?  Why do we condone a laptop or calculator as an appropriate tool, but not a medication? Does it have to do with the differences in their direct impact on the brain?  If so, then is there a moral difference between using a prescription medication and using large amounts of caffeine, which could elicit similar mental and physiological effects?

Another argument related to this idea of using stimulants as tools for achievement is whether it is “fair” for people to enhance their thinking using these drugs.  Is taking medications to achieve better simply another way to get one’s work done, or is it a form of cheating?

Would it be fair? Is taking a stimulant a form of cheating?

Do cognitive stimulants give an unfair advantage to some students over others?  Does it create an unjust environment where those who can afford or are willing to take the drugs are given an unfair leg up over those who don’t?  Is it “fair” that some students can afford to purchase such enhancements when others can’t?

In her article Brain Gain, Margaret Talbot writes,

“At many colleges, students have begun calling the off-label use of neuroenhancers a form of cheating. Writing last year in the Cavalier Daily, the student newspaper of the University of Virginia, a columnist named Greg Crapanzano argued that neuroenhancers “create an unfair advantage for the users who are willing to break the law in order to gain an edge. These students create work that is dependent on the use of a pill rather than their own work ethic.”

The question about cheating inevitably draws an analogy between using cognitive steroids to boost the mind and using steroids in athletic to boost physical strength. We generally acknowledge that using steroids in sports is unfair — it’s even illegal: so is doping our minds and different from doping our bodies?

Scientist Anders Sandberg says there should be no distinction, and that “cognitive doping” should be treated much like steroids are treated in sports: “If the goal of education is a competition for high grades, then the drugs would be a kin to doping and only add an unfair positional advantage to users…”

Yet others disagree, claiming that taking these medications is no different from other techniques students use to try to do better in school – invoking an argument similar to Greely.  One student writing about this topic said,

“Taking a study drug, while unhealthy and risky, should neither be considered illegal nor unethical…it’d be akin to saying studying for extra hours is somewhat unfair. How a person stays up has always been private business and varies person to person…Taking a study drug (should be) no more illegal than taking caffeine. Those who can afford to do more, get more. This is far from cheating, which is getting what you didn’t work for.  Debating whether drugs are fair is to debate whether we should compete at all.”

I think this argument is important to consider. Would the advantage given to those who are willing to take the drug be unfair over those who are unwilling to take the drugs? And would people start feeling coerced into taking the drugs if that was the only way to achieve at that level, much like athletes feel the pressure to take steroids in order to compete at the same level?  Extending it out, one might ask, what would happen from a distributive justice perspective if wealthy people have access to these cognitive drugs but people who can’t afford them don’t?  Would the gap between the rich and the poor widen?

Is there value in hard work that is undermined by using these drugs?

Another interesting perspective to consider is what role these drugs play in our conceptions of personhood. Have you ever had the experience of working so genuinely hard on something, and reaping the great rewards as a result of your genuine hard work?  Would this experience be undermined if you had relied on an artificial method of enhancement – a drug – in order to complete it?

Anjan Chatterjee’s article “Cosmetic Neurology” raises this concern, questioning what impact cognitive stimulants have on our concepts of character.  He takes the view that taking cognitive stimulants is indeed cheating, and therefore that taking these medications would erode our character. “Getting a boost without doing the work is cheating,” Chaterjee puts forth.  “And cheating cheapens us.”

Chatterjee also raises another interesting point, which is that these medications challenge the principle of accomplishing something on one’s own good will. Just like we don’t like it when athletes break records doped up on steroids, Chatterjee says, shouldn’t we hold the same judgment when someone “performs well” on a stimulant? We have long adopted the view that struggling builds character, and that eliminating pain altogether erodes that character.  In other words, the genuine hard work we put into things is important, and avenues that circumvent that hard work or augment them unfairly, undermines the entire achievement.  This issue seems particularly relevant in academia, where the analogy with steroid use in sports seems apt: would you respect a person less knowing they use a drug to enhance their thinking, much like we are disappointed by an athlete who engages in artificial enhancement?  If someone earns an A on a paper written on medication, are they as “worthy” of that A as they would be if they hadn’t taken it?

And one wonders, too, about the value of hard work, and whether it is lost in the midst of a stimulant-driven haze: is it really as valuable an experience to crank out a 10 page paper in one night on Ritalin as it is to work on it over time, sit with it, and truly learn from it?

Another question to consider in regards to personhood and values involves looking more generally at what types of thinking these medications encourage, and whether they are the types of thinking we want to be promoting. If we are to embrace the use of these drugs, then what value judgments are we placing on the idea that this type of alert productivity is necessarily the best type of thinking?

We automatically call medication that stimulates alertness “cognitive enhancement” – but should we?  It is well known that stimulants help people to focus, be more attentive, and more alert; yet, calling this type of thinking “cognitive enhancement” is not a technical term but rather a value judgment. Are there “cognitive trade-offs”  to these drugs — other valuable ways of thinking that these medications shut out? In creating a focused, attentive state of mind, what cognitive capacities might these drugs be undermining?

Indeed, many neuroscientists suggest that in promoting this type alert, “efficient” thinking, other types of thinking are de-emphasized in the brain.  Talbot notes:

“Cognitive psychologists have found that there is a trade-off between attentional focus and creativity. And there is some evidence that suggests that individuals who are better able to focus on one thing and filter out distractions tend to be less creative,” adding, stimulants “facilitate a pinched, unromantic, grindingly efficient form of productivity.”

Jonah Lehrer, a neuroscientist and author of “How We Decide,” adds that these cognitive stimulants can negatively impact creativity and prevent the type of thinking that leads to insightful breakthroughs.  To achieve better focus, he says on his blog The Frontal Cortex, there can be a trade off of more creative ways of thinking:

“While it’s commonly assumed that the best way to solve a difficult problem is to focus, minimize distractions, and pay attention only to the relevant details, this clenched state of mind may inhibit the sort of creative connections that lead to sudden breakthroughs.”

Many students may relate to this point: those who take these medications talk about how the papers they write on Ritalin or Adderall are long-winded, and obsessive about certain points, perhaps indicating this certain type of thinking that these drugs emphasize over others.  The student Alex interviewed in Talbot’s article said, “Often, I’ve looked back at papers I’ve written on Adderall, and they’re verbose.  They’re belaboring a point, trying to create this airtight argument, when if you just got to your point in a more direct manner it would be stronger.  With Adderall I’d produce two pages on something that could be said in a couple of sentences.”

So, while these drugs may help with memorization and focus, are they limiting the type of thinking that can enhance analysis, creativity, and open-mindedness? Might a student, in thinking they are creating better work on stimulants, actually be cutting themselves off from different, more creative ways of approaching their assignments?  And what does it say about a society that is placing value on shutting out these more creative types of thinking, in favor of what Talbot calls “a grindingly efficient form of productivity?”

One wonders if in trying to gain one type of thinking, we would be losing out on another.  Hasn’t everyone had the experience of a stroke of insight while falling asleep or taking a shower – times when the mind is not “pinched and attentive”, but precisely the opposite?  What effect would medicating the “wandering mind” have on insights that come precisely because the mind is wandering?

Do the risks justify the gains?

A final point to consider is the risks these drugs pose, which are an important feature to examine when looking at any technological tool. Indeed, the argument that stimulants could benefit society should not be presented without a fair look at how they could also limit or pose a risk to society as well.  So do the risks of these medications justify the gains?

It is generally accepted that there is a difference between therapy and enhancement — in other words, that there is a moral difference between giving someone a treatment to alleviate suffering caused by a disease and giving someone treatment when they are healthy in order to make them even better. For those who take these medications for attentional disorders, the risks of these medications are considered in balance with the disorder the person is suffering from; one assesses the risks of the medications with the severity of symptoms of ADHD and decides that it is worthwhile to manage the side-effects if the medication alleviates the symptoms of the disorder. But if we proliferate these medications to the general “healthy” public, are the potential benefits of alertness and attentiveness –which don’t necessary to alleviate suffering in any strict sense but are rather just a preferred or “enhanced” way of functioning– worth the potential harm?  Is it ethical to take these drugs, intended to treat disorders, purely for the sake of enhancement?

Another idea to consider is at what cost we are willing to enhance ourselves — and whether we accurately assess that cost when pursuing new modes of enhancement.  It seems that often when looking at new technologies the potential benefits are lauded and the risks are downplayed, and this issue is no different. Hank Greely’s argument, for example, suggests that we shouldn’t necessarily view Adderall and Ritalin any differently from the way we view glasses that correct our vision: what makes them different, if they are both tools to make us better?

The somewhat obvious response to Greely’s argument is that there are potentially far greater risks to taking these medications than there are to using eyeglasses, or a laptop, or calculators.  Indeed, stimulants known side effects include nervousness, headaches, sleeplessness, decreased appetite, and cardiac problems, and are classified as having a high potential for abuse.   Increased risk of ideations of suicide, as well as increased cases of cardiac arrest that have led to death have been reported, and have led to the FDA instituting a “black box” warning on most stimulant medications.  Many students who take these medications experience abnormal sleep and eating patterns, some not sleeping or eating anything substantial for long periods at a time, and can experience increased anxiety and even stimulant-induced psychosis.  And while some who use stimulants casually do so with few side effects, these more serious effects should not be overlooked: for those students who have experienced them, or for parents whose children suffered cardiac deaths or suicide, these effects are not exaggerated or embellished but very real, and important to bring to light.

There  seems to exist a view, both because the medications are so popular and because they are not “street drugs” but prescription drugs, that these medications are generally safe to take without one’s own prescription; but this is a powerful misperception. Indeed, prescription medications are not safe merely because they are available through prescription; drugs, prescribed or not, carry with them risks and side effects that can vary from person to person, and in some cases may have drastic effects.  Furthermore, taking a prescription medication for which you yourself don’t have a prescription –sharing a prescription with a roommate, or selling pills at the library– can be a dangerous undertaking, particularly when mixed in with a college lifestyle of alcohol and perhaps even other drugs. The toxicity of stimulants increases significantly when mixed with alcohol; and without a proper discussion with a doctor, a student is at risk to experience these dangers without a proper avenue set up to assess his or her own safety.

Moreover, if we are to advocate the proliferation of these drugs in the widespread population, we must acknowledge that the effects of cognitive stimulating medications in the healthy has never been formally studied.  We simply don’t know how these drugs are metabolized by these “healthy,” non-ADHD individuals, for whom these stimulants were unintended and remain untested.  And given that we are essentially the first generation of people who are using these medications so widely and for such long periods of time, the long-term risks are still unknown.   As Margaret Talbot writes, the effects of these drugs are being discovered “furtively, amongst the increasing number of Americans who are performing daily experiments on their own brains.”

So where do the risks of these drugs factor into the ethical debate? And in light of these issues, it seems important to ask, it is ethical to present the idea that these medications can be a tool for an achievement without acknowledging these very real drawbacks?  Advocating the use of these drugs based on the premise that there is no substantive difference between them and a laptop or a pair of eyeglasses, particularly in a school setting, seems not only misinformed, but irresponsible.  And one wonders, what impact does promoting these drugs as simply “tools for achievement” without a full acknowledgement of these risks have on a student’s perceptions of taking these medications?

Ultimately, is the argument really simply between choosing to take these medication to become “smarter”, and choosing not to take them and staying the same?  Or should it really be presented as a cost-benefit, where the idea of taking these medications to achieve attentiveness and focus is posed alongside the potential for these very real side effects?

Each of these issues – what effect these medications would have for academic competition, what effects they might have on concepts of personhood and thinking, and what the risks are, converges on one question: What might a neuro-enhanced society look like?

If Greely and others are to be believed, we have the opportunity to become smarter, more productive, and more focused by embracing the use of cognitive stimulants.  Why try to do less, when we could medicate ourselves to be able to do more?  Who, as Nicholas Selzter said, would want an upper limit on productivity?

Yet from a critical perspective, consider some of the potential fall out: might we imagine a time when employers expect—or even require – employees to take these drugs to achieve better? Could hospitals require doctors to take drugs in order to be more alert on their late night shifts?  Pilots to take the drugs for long trips?  Would the people undergoing surgery, or flying on the planes, come to expect these professionals to take them as well? Could it lead to an environment where students feel coerced or compelled to take drugs to perform better, in the same way some athletes may feel compelled to take steroids to keep up with competition?  Would we live in a society where, as Margaret Talbot writes, “we give children academic steroids along with their daily vitamins”?

The idea that we need to ‘enhance’ ourselves is certainly a persuasive one: it is clear we have increasing demands not only on our cognition but on the amount we are physically expected to accomplish in a given day — and it makes sense that we would feel the drive to need to keep up.   But as Paul McHugh, a psychiatrist at Johns Hopkins says in Talbot’s article, “Maybe it’s wrong-footed to fit people into the world, rather than trying to make the world a better place for people.”

A perspective to consider is this: to what future are we committing ourselves?  If we continue the effort to achieve, accomplish more, produce more, compete more, the cycle of needing to modify our brains to keep up will continue. It’s almost certain that in ten years from now, the debate will have moved on from the ethical issues of cognitive stimulating medications to the ethical implications of brain implants, or other types of even more invasive brain modifications. Will we want to continue the road to increasing our brain function indefinitely, to keep up with our own technological demands?  Is there a point at which we should decide we are busy enough, productive enough, and smart enough now?   In reality, the expectations placed upon students and those in the workplace – the demands for a non-stop, blackberry fueled workday, or the barrels of homework on top of extra curricular activities and day-to-day life – will only continue to grow if we as a society allow it too.  And our pursuit towards keeping up – whether it be with medications now, or brain implants down the line–will have to continue as well.

I would argue that the use of cognitive stimulants – a technological tool in and of themselves– is intricately tied to our relationship with the increasing use of technology in all areas of our lives, and that to look at the issue of “cognitive enhancement” one would need to examine what effect all of this technology could be said to be having on our lives in general: on our attention spans (those attention spans which we feel compelled to take pills in order to get a handle on); on the belief that a better society is one that is more productive, efficient, and fast; and on the idea that if we can do something, we can always do it faster, and better.

I think Talbot makes an interesting point in her article, about what road we may be paving for ourselves:

“All this may be leading to a kind of society I’m not sure I want to live in,” she writes. “A society where we are even more overworked and driven by technology than we already are and where we have to take drugs to keep up.”

Conclusion

As technology continues to develop, more medications that can influence our brain chemistry –and eventually, more technologies, whether they be brain implants or currently inconceived of brain modifications — will be marketed as the next big thing in cognitive enhancement.  One could either say these scenarios present an opportunity to create more advancements using technology, or take the view that we have created a problem through technology that we are trying to solve using more technology.  Either way, it seems important to establish firm ethical guidelines about how we are to handle these issues.  If not, the use of these technologies will continue to be dictated by social pressure, rather than by principle.

It’s hard to separate out the “ethical” uses of these drugs form their neurological risks; the philosophical principles raised by this issue– as with many issues in technology and health — are somewhat separate from the real life risks these technologies pose. I think it’s important to acknowledge though, particularly in light of articles such as Greely’s which praise “smart drugs” but somewhat dismiss their risks, that the use of cognitive stimulants amongst people – amongst children, students, and those in the workplace– is an ongoing, uncontrolled experiment.   And moving forward, it seems important that we frame the argument appropriately.  Cognitive stimulants are not “smart pills”– indeed, no one takes Ritalin and becomes Einstein, or learns their entire Biology textbook instantaneously.  Rather, cognitive stimulants are drugs that manipulate brain chemistry in a way that, in many people – but certainly not all – increases their ability to focus and pay attention, and often to sleep less and work more.  Choosing to encourage the use of these medications is not promoting becoming “smarter,” necessarily, but promoting a type of brain state associated with these effects, among other, less desirable ones as well.

But the question at hand is not merely about whether students, or people in general, should take drugs to become “smarter.”   Perhaps the question we should be asking ourselves is whether the pursuit of these “cognitive enhancing drugs” would really be enhancing our lives at all.  Might we look deeper into this debate, and challenge some of the assumptions upon which it rests?  Maybe we should challenge the idea that these drugs are enhancing the way we think, by making us more alert and more “grindingly efficient.”  Maybe we should challenge whether this type of uber-efficient, speed-driven, hyper-productive society is really the type of society we want to be promoting.  Maybe we should focus not so much on the question of whether students should take these medications, but on where the perceived need for these medications arises — on what it says about an academic environment where there is so much pressure to focus, to be more productive, and to get more work done that students feel they need medications just in order to keep up.  Maybe we should reframe the debate, and ask ourselves whether it is our conception of what it means to be “enhanced” that is really what needs to be modified.

Questions

Consider some of the ethical arguments surrounding the issue of cognitive stimulants: is taking a cognitive stimulant without a prescription unethical?  Does it constitute cheating? Should it be viewed as “cognitive doping,” akin to using steroids in athletics?  Does it undermine one’s ‘personhood’ by helping one to avoid the challenges of discipline and failure? Do the risks of the medications justify the gains?

What role do societal pressures — academic, social, and technological — play in this debate? How does our relationship with technology factor into our approach to the use of cognitive stimulating medications?

Watch a CBS News segment called “Adderall U” featuring an interview with two students who take cognitive stimulants:

Part 2:

It’s interesting to consider how we decide what the rules are about which drugs are deemed socially acceptable and which ones are not.  We condone (not only condone, but actively rely on) certain substances like caffeine, guzzling down cups of coffee and cans of Red Bull without a second thought about their “ethical implications.”  We condemn marijuana as illegal but allow a much more dangerous drug – alcohol – to be consumed at will after the age of 21.  We think it’s permissible to use coffee and chain-smoking cigarettes to pull an all nighter to complete work but would gape at someone snorting a line of cocaine for the same reason.  How are these lines we draw–the ones that call a certain brain-altering substance taboo and another one completely embraceable– determined?  Do they involve a careful assessment of their effects on the brain?   A standardized measure of risks?  Do they come from some subjective evaluation grandfathered in by socially determined forces?

I raise this point because this post is a response to an article from the scientific journal Nature published in 2008 called “Towards The Responsible Use Of Cognitive Stimulants In The Healthy,” an article which gathered together reputable academics from elite institutions across the country and declared that cognitive stimulants like Adderall and Ritalin should not only be permissible to use in the normal, healthy population, but that their use should be encouraged.  A society of individuals taking these cognitive stimulants would be more smarter, more efficient, and more productive, they said, and therefore we shouldn’t shy away from these drugs, but should embrace them.  The article states:

“Cognitive enhancement has much to offer individuals and society…We should welcome new methods of improving our brain function.  In a world in which human work-spans and life spans are increasing, cognitive enhancement tools – including the pharmacological—will be increasingly useful for improved quality of life and extended work productivity, as well as to stave off normal and pathological age-related cognitive declines.”

Hank Greely, a law professor who directs the Stanford Center for Law and the Biosciences and spearheaded this article, makes the point firmly: If we can manage the risks of these medications, he writes, why wouldn’t we pursue a future of widespread “cognitive enhancement”? A future where we could be smarter, more focused, and more alert?  And admittedly, when put this way, Greely’s argument sounds pretty convincing: no one can deny that being smarter and thinking faster would be a net-net gain for our society.

But maybe that’s a faulty assumption.  As with any ethical issue, there is a powerful counter-side to consider to this “faster = smarter = better” paradigm.  In his guest post below, Santa Clara Graduate Psychology adjunct lecturer Dr. Sean Hatt challenges Greely and his colleagues conclusions, outlining a number of reasons why the encouragement of these drugs is a worrisome path to head down.  Indeed, these so-called “smart drugs” are not a panacea for our wandering minds; they come at a real cost, a cost that Greely’s article, one could say, blithely glazes over and ignores.  The risks and effects of these medications can be substantial, particularly for the young populations who take them (one study even found increased death rates in children); and in ‘focusing’ our minds, the use of these drugs can stifle more creative types of thinking.

Dr. Hatt also raises an important question about what promoting these medications says about the types of values we are fostering as a culture.  Is advocating for drugs that enable people to do everything faster and more efficiently really cultivating the type of human beings we want to be? Read his post and consider the idea: what is the symbolic meaning of the pursuit of cognitive stimulants?  What does it say about who we are as human beings, about what we want, and what we value?  Why do we consider these types of drugs – which Margaret Talbot described as facilitating “a pinched, unromantic, grindingly efficient form of productivity,” cognitive enhancement?

Dr. Sean Patrick Hatt is an adjunct lecturer in the Graduate School of Education, Counseling Pyschology, and Pastoral Ministries at Santa Clara University.  He wrote his doctoral dissertation on the social construction of Attention-Deficit/Hyperactivity Disorder in Poor African American And Affluent White American Families, which can be read on his website, www.seanpatrickhatt.com.

Cognition Enhancing Drug Use: Sacrificing Depth for Speed

Guest Blog Post by Sean Patrick Hatt, Ph.D.,

Department of Counseling Psychology
Santa Clara University

As a scholar and clinician interested in the social construction of Attention-Deficit/Hyperactivity Disorder as well as other mental illnesses more generally, I was asked to render a brief opinion regarding the use of prescription stimulants like Ritalin and Adderall by otherwise healthy people simply for the purpose of getting better grades, or working faster or more efficiently.

At the surface, it seems fairly benign. After all, we have been giving these drugs to our young school-aged children for decades to help stem disruptive behaviors or address difficulties in focusing attention in the classroom. In fact, the National Institutes of Mental Health (NIMH) recently published research touting the possible efficacy of stimulant medication in children as young as three years of age (Greenhill, et al., 2006).

That all makes it understandably easy for people to wonder how dangerous these drugs could possibly be. And, if they do promise to help healthy, responsible, intelligent people get far more work done, more quickly and with fewer distractions, what’s the harm? How different is this from drinking coffee or an energy drink?

If you find yourself nodding in agreement as you read, you have company in some very reputable places. In a recent issue ofNature, which is widely recognized the world over as one of our more prestigious scholarly publications, clinicians and scholars from Harvard Medical School, Stanford University Law School, the University of Cambridge, the University of Manchester, UC Berkeley, and the University of Pennsylvania collaborated on an article advocating the “responsible use of cognitive enhancing drugs by the healthy” (Greely, et al., 2008).

Greely's Article, From Nature

While exploring the question is almost certainly a worthwhile endeavor, this article, and the idea it seeks to advance, concerns me for a number of reasons, particularly given its rather authoritative status. Acknowledging the brevity of this forum, allow me to elaborate upon three of them, and then offer another way of thinking about this issue.

First, the article frames the subject in terms that scarcely anyone would take issue with. Who wouldn’t support “cognitive enhancement?” After all, isn’t that why people attend a University in the first place? I believe special care should be taken to employ more neutral language to frame a debate like this so as not to unduly bias the conversation, or even marginalize dissenting voices before they can be heard. As a community of teachers and researchers, let us respect the power inherent in our positions as constructors of new knowledge, and take particular care not to unintentionally cloak what may be a wolf in a sheep’s clothing.

This brings me to my second point: The article barely acknowledges the potential health risks of taking the drugs in question, and only touches upon the topic in rather general terms. In my opinion, this only serves to further support the apparently innocuous nature of this proposal.

These are powerful pharmaceuticals that carry a long list of potentially serious risks, particularly in young people with still-developing brains

Allow me to fill in the blanks on this latter point with a few specifics. In spite of their seemingly ubiquitous presence, drugs used to treat ADHD are not at all similar to the caffeine in coffee or energy drinks. These are powerful pharmaceuticals that carry a long list of potentially serious risks, particularly in young people with still-developing brains. Adverse drug reactions in stimulant formulas include impaired growth (Swanson, et al., 2007), insomnia, agitation, hypomania, mania, seizures, physical withdrawal, rebound effects, dependence (Breggin, 1999a, 1999b), and even psychosis (Breggin, 2000). Non-stimulant formulas also present safety problems, and their manufacturers were recently ordered by the United States Food and Drug Administration (FDA) to include a “black box” warning regarding the potential for increased suicidal ideation in adolescents (Carey, 2005). The black box was also subsequently ordered by the FDA for some popular stimulant formulas given an increased risk of sudden death (Pettypiece & Blum, 2006).

Third, the article focuses upon only one family of “enhancements” as if they are all that might be possible or desirable—speed, memory and attention. It makes this idea sound every bit as simple as upgrading to a new computer with a faster microprocessor, more RAM and a bigger hard drive. A growing minority in the scholarly community who have been studying the legitimate therapeutic uses of a variety of other psychoactive substances—like MDMA (Parrott, 2007) for example—would have much to say about this limited definition of enhancement. If the scholarly community at large wishes to open the question of the legitimacy of “cognitive enhancement through drug use” for a comprehensive hearing, why not include these substances and what they may offer as well?

I raise that potentially controversial point as a way of leading into what for me is the heart of the matter. It’s not about advocating for all drugs equally. It’s about questioning what this says about our culture. Should we allow the pharmaceutical industry, corporate-owned media, allopathic medicine, the academy, and the Law decide for us what is worthy of enhancing and the means by which we should seek to do so?

Allow me to explain further. Greely and colleagues (2009) talk briefly about the issue of fairness, which I think is salient here, but mainly as a means of focusing in upon this deeper thread of the conversation. Specifically, they compare the use of cognitive enhancing drugs by some students and not others with the notion of some being allowed to use calculators on a math exam while others are limited to pencils and scratch paper. Further, they wonder how this divide might show up as a function of access given socio-economic status. Whatever the case, the authors imply that allowing the use of cognitive enhancing drugs by some may amount to a form of indirect coercion whereby students feel they have no choice but to take the drugs in order to compete. While those are all worthy points from both sociological and psychological perspectives, this begs an even more fundamental question the authors fail to address: Compete for what, and to what ends?

Paul Tillich (1999) framed a convincing case that our culture increasingly tends to overemphasize what he called  “the horizontal dimension” of life. I see this showing up in how we relate to our world as a place filled with objects that are separate from us—including, ironically enough in this case, our own brains. These detached objects exist only to be exploited, acquired, shaped, produced, controlled or manipulated, with ever more efficiency, and for ever increasing personal gain.

The result of unconsciously proliferating such cultural practices is a loss of the dimension of “depth” in our discourse and in our lives

The result of unconsciously proliferating such cultural practices is, sadly, a loss of the dimension of “depth” in our discourse and in our lives. Tillich (1999) maintains that losing depth amounts to a disconnection from Spirit at the most universal level: namely, “the ability of man to ask passionately the question of the meaning of our existence.” To my mind, that’s where an education at a place like Santa Clara University strives to set itself apart, and often does. So the question for me becomes, “Do we want to risk losing that?”

I’m not suggesting that we ought to ignore the acquisition of skills and excellence in academic performance in the “horizontal” sense of their meaning in the world. What I am suggesting is that we needn’t emphasize or “enhance” them at the expense of students’ concerns for their own Being, or the state of Human Being more broadly.

In my opinion, that is the hidden price tag attached to “cognitive enhancement” as long as it’s all about speed—both literally and more symbolically.

In closing, the awe inspiring opportunity which lies before each of us is to creatively and authentically engage the tension between the horizontal and the deep, to the best of our God-given abilities, as professors and students and staff alike. When we do, we will co-create an education that develops heart and mind, body and soul, cognitive power and depth of feeling, efficiency and creativity. Best of all, such an education will en-courage us all to embody as a whole community what I have come to understand as foundational values of the Jesuit tradition: the sacred union of intellect, wisdom, skillful means, and love, as expressed in service to all of Humankind.

Now that is the sort of enhancement I can fully support.

References

Breggin, P. R. (1999a). Psychostimulants in the treatment of children diagnosed with ADHD: Part 1–Acute risks and psychological effects. Ethical Human Sciences and Services, 1(1), 13-33.

Breggin, P. R. (1999b). Psychostimulants in the treatment of children diagnosed with ADHD: Part II–Adverse effects on brain and behavior. Ethical Human Sciences and Services, 1(3), 213-242.

Breggin, P. R. (2000). Confirming the hazards of stimulant drug treatment. Ethical Human Sciences and Services, 2(3), 203-204.

Carey, B. (2005). F.D.A. orders new warning on Attention-Deficit drug. The New York Times.com. Retrieved from http://www.nytimes.com/2005/09/30/health/30drug.html?ex=1157169600&en=a11a780cbe726cd4&ei=5070

Greely, H., Campbell, P., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., et al. (2008). Towards responsible use of cognitive-enhancing drugs by the healthy. Nature (December 2008), 702-705.

Greenhill, L. L., Kollins, S., Abikoff, H. B., McCracken, J. T., Riddle, M., Swanson, J. M., et al. (2006). Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 45(11), 1284-1293.

Parrott, A. C. (2007). The psychotherapeutic potential of MDMA (3,4-methylenedioxymethamphetamine): an evidence-based review. Psychopharmacology, 191, 181-193.

Pettypiece, S., & Blum, J. (2006). Glaxo, Shire stengthen risk warnings on ADHD drugs. Bloomberg.com. Retrieved from http://www.bloomberg.com/apps/news?pid=20601085&sid=alBMR22v6xpI&refer=europe

Swanson, J. M., Elliott, G., Greenhill, L. L., Wigal, T., Arnold, L. E., Vitiello, B., et al. (2007). Effects of stimulant medication on growth rates across three years in the MTA follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 46(8), 1015-1027.

Tillich, P. (1999). The essential Tillich: an anthology of the writings of Paul Tillich. Chicago: University of Chicago Press.

Questions:

Professor Hatt raises important critiques about Greely’s article, highlighting the oft-downplayed risks of the medications, and asking a more fundamental question about what the pursuit of these drugs says about our culture, in which we are emphasizing competition and speed while not promoting other parts of being.  Do you agree with him that these medications promote one type of ‘being’ at the expense of others?  What types of thinking — of being — are de-emphasized as a result of these medications?

Considering both Greely’s and Dr. Hatt’s arguments, do you think the use of cognitive stimulants by the general public would benefit or detract from society?

And what does this mean to you? It seems fair to say that currently, most people don’t concern themselves with their genetic profiles in their day-to-day lives.  Surely we read about genetics in the media: what genes are linked with what traits, what advancements are being made in the field of medicine with the growing knowledge of genetic information.  But our society certainly doesn’t conduct itself like the science-fiction movie Gattaca, where each person is branded with his or her genetic likelihoods from birth and assigned societal roles accordingly. We are generally oblivious to our own genetic profiles, and pay selective attention to findings about genes mostly when faced with a pressing health problem.  For the most part, we carry on our lives with little knowledge about our own genetic makeup and what that information might tell us about ourselves.

This, however, is changing.

Genetic testing is becoming more and more available and affordable, and thus more accessible to the general public.  Whereas previous genetic tests used to cost thousands of dollars and were available primarily through a doctor’s order, now an online kit and a couple hundred dollars is all one needs to access his or her genetic profile.

Want to know your genetic family history?  Genetree.com will help you find out your genetic cousins and learn about your ancient paternal ancestry for less than $150.

Interested in the disease you may be at risk for, or the personality traits for which you are genetically predisposed? Just mail in a tube of your saliva to 23andMe.com and for $399, receive a full profile back in 6-8 weeks.

Unlucky in love?  Check out Scientificmatch.com, an online dating service that specializes in finding your perfect match – genetic match, that is.  Scientific Match claims you’ll have “a greater chance of a more satisfying sex life” and a “lower chance of cheating” if you let their matchmaking system find you someone with compatible genes.

Gear up, everybody: the personalized genomic revolution has begun.   And it’s not only taking place through the private companies offering you information based on small pieces of your genetic code; The Personal Genome Project is hoping to recruit 100,000 volunteers to have their entire genomes sequenced and posted online .  A handful of famous scientists, including George Church and Steven Pinker, are 2 of 10 people who have already put their entire genomes on the web for all to see, in hopes that genetic transparency will lead to better research and will debunk some of the fears people have about genetic testing.

But personalized genomics coupled with this gene-sharing mentality raises many important questions.  Today’s post asks, what issues need to be considered before you go spitting into that tube?

The Center For American Progress’s Rick Weiss gives a good overview of direct-to-consumer genetic testing in the following YouTube video, outlining what people should keep their eyes out for as personalized genetics develops.  He explains that given that we are beginning to be able to identify which genes are associated with increased risk of disease, a new wave of personalized, predictive medicine is on the horizon; but the information often isn’t easy and clear cut to interpret, and direct-to-consumer companies making tests available to consumers online “opens up a whole new arena of web based risks”, particularly in light of the lack of regulation these internet genomics companies have right now.   Watch Weiss’s overview below:

A group of leading thinkers on this issue convened last year at a forum sponsored by The Commonwealth Club entitled, “A Closer Look At Genetic Testing” to examine some of these risks that Rick Weiss alludes to.  They raised a broad range of issues that we are facing with the personal genomics revolution, in regards to privacy, ethics, and law.  Here are some excerpts of their talk:

Video 1:

In this first clip, Pacific Research Institute’s Daniel Ballon discusses the implications genetic information has for the public sphere from a civil liberties perspective.  He asks, How will genetic information be used in law enforcement when it comes to arresting and convicting people who commit crimes? Should a warrant be required to get genomic information? How might genetic information be utilized to manage public health issues? If we identify a gene that indicates someone is very susceptible to catching swine flu, for example, might the government take that information and preemptively quarantine a portion of the population which fits this profile? What about genes and national security?  Might “a genetic profile for a potential terrorist” be conceived of, and if so, could we preemptively arrest them?

The issues raised by genetic testing from a civil liberties perspective are profound, he says, and should be considered carefully by those who are submitting their genes to private databases that may be “mined” by the government in years to come.  (The Federal Trade Commission adds, “Protect Your Privacy.  At-home test companies may post patient test results online.  If the website is not secure, your information may be seen by others.  Before you do business with any company online, check the privacy policy to see how they may use your personal information, and whether they share customer information with marketers.”):

Video 2:

The next segment raises a number of fascinating questions, all predicated on the following premise: genetic information never goes away.  Unlike a social security number, which, if it gets ‘stolen’, can be replaced by a new one, you can’t simply apply for a new genome. So if you choose to get aspects of your genome mapped now, what problems might this pose for you in the future?

First, as Mark Gerstein of Yale University says, there are issues of privacy and consent, not only for you, but for your family as well. If you are getting your genome mapped to find out your risk for a genetic disease, you are not only finding out information about your own genes but about your relative’s genes, your parent’s genes, your children’s genes – even your children’s children’s genes, and so on. Gerstein says this could lead to a “hidden time bomb”, where we will in the future be able to read things into various people’s families and descendents, including about people, like children, who didn’t participate in that consent to have that information shared.  And though there are some steps being taken towards protecting genetic information like The Genetic Information Non-Discrimination Act, one wonders about potential scenarios: could a test you get now affect a grandchild’s ability to get health insurance?

Another issue posed:  Genetic testing might be seen as fun and interesting to take part in now (particularly as companies offer services like dating matches or ancestral trees) but information you find out about your genome in current early stages of genetics might pose problems for you in the future when the field becomes more developed. Stanford University Bioethicist David Magnus adds, “Things that you think right now are not problematic could turn out to be problematic” in the future.  What if you share genetic information that doesn’t mean anything now given our current knowledge base, but in ten years, is found to be linked with an incriminating mental or physical disorder?

Video 3:

Issues of eroding privacy in the internet-era, as well as the tendency for young people to be “over-sharers” on the web, characterize our generation.This last segment asks, is the web 2.0 generation going to care about genetic privacy at all?

“In a way, it’s still an empirical question and it will be interesting to see how it plays out,” said David Magnus.  “Are there going to be people who are right now comfortable sharing but when they see all the implications, they’re gonna be nervous about it?  Or is there really a generational shift, where we really are facing a group of people…a generation where they just don’t care?”

The issues of making genomes public, as the previous two videos illustrated, are important to consider.  Will our generation treat gene information sharing much like we treat personal information now?

I’m reminded of an iPhone application in development called “MyGenome”, which allows users to store their genetic information on the iPhones, browse their genomes by chromosomes, look up reactions to medicines they may be genetically predisposed for, and importantly, to share their information with others.  A MyGenome user cannot only compare their genome to famous genomes that have been sequenced, but share with friends and family, and hypothetically, with any iPhone user within wireless range.

Other examples of gene sharing are easy to conjure: it’s not hard to imagine a future Facebook app that finds you “genetically-matched” friends, or a ‘viral’ note entitled “25 Things My Genes Say About Me” spreading around. Is this what Gerstein means when he says sharing genetic information will all start seeming fun and interesting, but will lead to us sharing information without knowing where it might lead?

Closing:

The ability to know our personal genetic information is a profound undertaking that not only transforms the way we view and treat disease, but the fundamental way we define ourselves, our public policies, and our futures.   Issues of privacy therefore seem tantamount; exercising care and caution when approaching genetic information seems not only wise, but critical.

But as the up and coming generations face a loss of privacy left and right as a result of evolving technologies, one wonders: will genetic privacy be the next to go?  And if so, what might the consequences be?

Questions:

1. Do you consider knowing your genetic profile to be an important part of knowing who you are (or who you’ll be)? Would you consider getting portions of your genome mapped?  Why or why not?

2. How do you think the “web 2.0” generation will handle the issue of genetic information and privacy?  Will they be more cautious when it comes to genetic information than they are about other information?

3. Michio Kaku wrote in his essay, “Second Thoughts: The Genetics of  A Brave New World“: “Since time immemorial, societies have committed some form of genetic discrimination.  People with obvious deformities or diseases were taunted, labeled witches (as in Huntington’s disease), systematically isolated from society…What is new, however, is that today it will be possible to screen individuals for a genetic disease even if the disease never appears.  Someone who may never suffer from a particular genetic disease may be denied insurance or a job if the person has a high probability of developing a genetic disease.” Do you think genetic discrimination will be a significant problem as more and more people get genetic tests? Would you forego a genetic test for fear of genetic discrimination?

Have you heard of “designer babies”?  Or perhaps you saw or read My Sister’s Keeper, a story about a young girl who was conceived through In Vitro Fertilization to be a genetically matched donor for her older sister with leukemia? The concept of selecting  traits for one’s child comes from a technology called preimplantation genetic diagnosis (PGD), a technique used on embryos acquired during In Vitro Fertilization to screen for genetic diseases.  PGD tests embryos for genetic abnormalities, and based on the information gleaned, provides potential parents with the opportunity to select to implant only the “healthy”, non-genetically diseased embryos into the mother.  But this genetic testing of the embryo also opens the door for other uses as well, including selecting whether you have a male or female child, or even the possibility of selecting specific features for the child, like eye color.  Thus, many ethicists wonder about the future of the technology, and whether it will lead to babies that are “designed” by their parents.

Today’s post is an exploration of the ethical issues raised by prenatal and preimplantation genetic diagnosis, written by Santa Clara Professor Dr. Lawrence Nelson, who has been writing about and teaching bioethics for over 30 years.  Read on to examine the many ethical issues raised by this technology.

Lawrence Nelson is a lawyer and an Associate Professor of Philosophy at Santa Clara University.  He has written about and taught bioethics for over 30 years.  He can be reached at lnelson@scu.edu.  This blog is in part derived from his chapter on PGD in A Textbook of Perinatal Medicine, edited by A. Kurjak, 2006 edition, CRC Press-Parthenon Publishers, pp. 179-189.

Prenatal and Preimplantation Genetic Diagnosis

Background:

The overwhelming majority of people on earth, due to a wide range of reasons, beliefs, bodily motives, and attitudes–some good, some bad, and some in the moral neutral zone–reproduce.  They are the genetic, gestational, and/or social (rearing) parents of a child.  Birth rates in some countries are at a historic low (Japan‘s is beneath replacement with the consequent deep graying of an entire society).  In others, mostly in the developing part of the world where infant and maternal morbidity and mortality (not to mention poverty and disease) are quite high, birth rates remain similarly high.

In the economically developed part of the world, the process of making and having babies has become increasingly medicalized, at least for those fortunate enough to have ready access to the ever more sophisticated tools and knowledge of obstetrical medicine.  From the time prior to pregnancy (fertility treatments, in vitro fertilization) to birth (caesarean delivery, high tech neonatal intensive care) and in between (fetal surgery), medical science and technology can help many to reach the goal any good parent should want: the live birth of a healthy child to a healthy mother.

“Medical and biological sciences can together determine whether a fetus will (or might) have over a thousand different genetic diseases or abnormalities”

Parallel to obstetrical medicine, science and technology have progressed immensely in another are over the last 30 or so years.  The Human Genome Project (and the related research it has stimulated) has generated an amazing amount of knowledge about the nature and identity of normal–and abnormal–human genetic codes.  Now the medical and biological sciences can together determine whether a fetus will (or might) have over a thousand different genetic diseases or abnormalities.  Ultrasound examination can look into the womb (quite literally) and see developmental abnormalities in the fetus (such as neural tube defects like spina bifida and anencephaly).  Even a simple blood test done on a pregnant woman can determine whether the fetus she is carrying has trisomy 21 (down syndrome), a genetic condition associated with mental retardation and, not infrequently, cardiac and other health problems.

Pregnant women who have health insurance that covers obstetrical care (and many millions of American women do not), particularly if they are older (>35 years), are more or less routinely offered prenatal genetic diagnosis by their obstetricians.  Chorionic villus sampling is a medical procedure that takes a few fetal cells from the placenta and can be done around 10 weeks after the woman’s last menstrual period.  These cells can then be analyzed to determine the presence of genetic abnormalities.  Amniocentesis is a medical procedure that obtains fetal cells from the amniotic fluid and is usually done later in pregnancy, typically after 14 weeks following the woman’s last menstrual period.  When done by experienced medical professionals, both procedures carry about a 0.5% risk of spontaneous abortion.  The genetic analysis done on these fetal cells can determine the presence of fatal genetic diseases (such as Tay-Sachs, trisomy 13 and 18), disease that can cause the born child much suffering (children with Lesch-Nyan, for example, compulsively engage in self-destructive behavior like lip chewing, while children with spinal muscular atrophy have severe, progressive muscle-wasting), and conditions that typically cause mental retardation (such as Fragile-X and Emanuel syndrome).

Although tremendous strides have been made in genetic science’s ability to detect chromosomal abnormalities, precious little success has been achieved in treating genetic disorders directly either prenatally or postnatally.  Some symptomatic treatment may well be available, but almost nothing that will actually cure or significantly ameliorate the effects of the disease.  A pregnant woman who wishes to avoid the birth of a child with genetic disease has little alternative but to seek termination of the pregnancy.

The science and technology of assisted reproduction (in this case in vitro fertilization [IVF]) meets the science and technology of obstetrical medicine in preimplantation genetic diagnosis (PGD).  Embryos are created in vitro by mixing oocytes taken from the woman who intends to gestate one (or more) of them from a donor, and sperm taken from her partner or a donor.  Genetic analysis is performed on one or few cells from each embryo, the loss of which does not affect the embryo’s ability to develop normally once implanted in a womb.  Only those embryos free of detectable genetic abnormalities are then implanted in the woman’s womb in the hope that they will then attach to the uterine wall and develop normally.  While success rates for implantation vary, many women have given birth following PGD.  The main advantage of PGD over chorionic villus sampling and amniocentesis for many women and couples is that it avoid the need for a surgical abortion to end an undesired pregnancy, although it does result in discarding the affected embryos.

What ethical issues are raised by Prenatal Genetic Diagnosis and Preimplantation Genetic Diagnosis?

Prenatal genetic diagnosis (PrGD) and preimplantation genetic diagnosis (PGD) both raise a number of serious ethical questions and problems.

What role does money play in ethical issues with PrGD and PGD?

1.  Both services are quite expensive (especially PGD which is typically not covered by even private insurance and has the added cost of IVF) and are not available to all who might need or want them.  This raises difficult questions of social justice and equity, including whether coverage for these services is morally responsible when social resources for all health care services (those that are life-saving and preventive) are seriously limited.

2.  As PGD is generally paid for directly by the persons who utilize it, ethical questions arise about the means clinics use to attract patients and the information they provide them about its risks and benefits.   Clinicians are in a fiduciary relationship with their patients and are obligated to act so as to deserve and maintain the patient’s trust and confidence that their wishes and best interests are being faithfully served.  Consequently, the marketing of infertility services ought to place the good of patients above other interests (especially a clinician’s or clinic’s own economic interests), should not induce patients to accept excessive, unneeded, or unproven services, and should adhere to high standards of honesty and accuracy in the information provided to prospective patients.

What is the moral status of an embryo?

3.  Both PrGD and PGD result in the destruction of embryos and fetuses.  If, as some contend, all human embryos and fetuses have the same moral status as live-born persons, then they are entitled to basic rights, including the right not to be killed arbitrarily or for the purpose of advancing the interests of other persons.  On this view, both PrGD and PGD would be seriously morally wrong.  The opposing view would hold that embryos and fetuses lack any moral status whatsoever as they lack any properties, such as sentience or other cognitive traits, that determine moral standing and so can be destroyed at will.

Perhaps the more commonly held–and more ethically defensible–position is that human embryos and fetuses deserve some modest moral status because they are alive, have some degree of potential to become human persons, and are in fact valued by moral agents whose views deserve at least some respect and deference from others. Nevertheless, they do not possess the full and equal moral standing of persons because they lack interests and other moral claims to personhood.  Having a modest level of moral status does not preclude the destruction of embryos and fetuses for a morally serious reason or purpose, and the informed and conscientious choice of the persons who created the embryos to prevent the birth of a child with a serious genetic disease or abnormality is widely (though by no means universally) considered to be such a reason

Does PrGD and PGD lead to discrimination against the disabled?

4.  Recently disability activists have strongly challenged what they deem to be the basic assumption underlying PrGD and PGD: reducing the incidence of disease and disability is an obvious and unambiguous good.  They rightly criticize certain views that support this assumption: that the disabled’s enjoyment of life is necessarily less than for nondisabled people; that raising a child with a disability is a wholly undesirable thing; and that selective embryo discard or abortion necessarily saves mothers from the heavy burdens of raising disabled children.  However, the ethical critique of the disability activists goes much deeper than this quite proper debunking of broadly drawn and inaccurate assumptions about life with any disability.  First, they contend that the medical system tends to exaggerate the “burden” associated with having a disability and underestimates the functional abilities of the disabled.  The activists also point out how medical language reinforces the negativity associated with disability by using such terms as “deformity” or “defective embryo or fetus.”  Second, and more importantly, the disability activists claim that the promotion and use of PGD and traditional prenatal diagnosis “sends a message” to the public that negatively affects existing disabled people and fosters an increase in the oppression and prejudice from which they regularly suffer.

“Adults who wish to reproduce are ethically obligated to do so in a responsible manner, and this means gathering and assessing fair and accurate information about what the future might hold for them and the child they might produce.”

Insofar as individual clinicians do, in fact, exaggerate the problems and burdens of living as an individual with a disability or of living with a disabled person as a parent or family member, then they are doing a moral disservice to the people they are duty bound to be helping.  Adults who wish to reproduce are ethically obligated to do so in a responsible manner, and this means (insofar as it is possible in a world about which we have imperfect knowledge) gathering and assessing fair and accurate information about what the future might hold for them and the child they might produce.  Clinicians (especially genetic counselors) should endeavor to provide this kind of information, supplemented–if at all possible–by the firsthand information that comes from those who have actually lived with disabilities of various kinds as parents of the disabled or from the disabled individuals themselves.  On the other hand, these conditions are simply not utterly benign or neutral as each may–and often does–involve what can fairly be described as an “undesirable event such as pain, repeated hospitalizations and operations, paralysis, a shortened life span, limited educational and job opportunities, limited independence, and do forth.” [1]

Discrimination against persons with disabilities is just as morally repugnant as discrimination against persons based on race, religion, or sex, but it is not at all clear that PrGD and PGD reinforce or contribute to this in any manner.  Regardless of how society might change (as it surely ought to change) its attitudes and practices to decrease or, better, eliminate the socially created disadvantages wrongly placed on the disabled–and regardless of how individual persons might change their views on the prospect of knowingly having a child with a serious disability, other persons will prefer not to have a child with a serious disability, no matter how wonderful the social services, no matter how inclusive the society.  It is this individual choice that PGD preserves, although the clinicians who offer PGD have a moral obligation to explore their own and their patients’ attitudes about, and understanding of, disability so these individual decisions can be made fairly and responsibly with accurate information about the real world of life with and without disability.

Should people be able to select the sex of their baby?

5.  Both PrGD and PGD identify the sex of the embryo or fetus.  This raises the question of whether it is ethically permissible for an embryo to be discarded or a fetus to be aborted because of sex.  The selection of an embryo’s sex via PGD is done for two basic reasons: (1) preventing the transmission of sex-linked genetic disorders; and (2) choosing sex to achieve gender balance in a family with more than one child, to achieve a preferred order in the birth of children by sex, or to provide a parent with a child of the sex he or she prefers to raise. [2]  While little extended ethical debate exists regarding the former, sex selection for the purpose of preventing the transmission of sex-linked genetic disease, the latter is the subject of heated ethical disagreement.

The ethical objections to sex selection for nonmedical reasons can be grounded both in the very act of deliberately choosing one sex over the other and the untoward consequences of sex selection, particularly if it is performed frequently.  Sex selection can be considered inherently ethically objectionable because it makes sex a determinative reason to value one human being over another when it ought to be completely irrelevant: females and males as such always ought be valued equally and never differentially.  Sex selection can also be ethically criticized for the undesirable consequences it may generate.  Choice by sex supports socially created assumptions about the relative value and meaning of “male” and “female,” with the latter almost universally being considered seriously inferior to the former.  By supporting assumptions that hold femaleness in lower social regard, sex selection enhances the likelihood that females will be the targets of infanticide, unfair discrimination, and damaging stereotypes.

Proponents of the ethical acceptability of sex selection would argue that a parent’s desire for family balancing can be–and typically is–morally neutral.  The defense of family balancing rests on the view that once a parent has a child of one sex, he or she can properly prefer to have a child of the other sex because the two genders are different and generate different parenting experiences.

To insist [that the experience of parenting a boy is different from that of parenting a girl] is not the case seems breathtakingly simplistic, as if gender played no role either in a person’s personality or relationships to others.  Gender may be partly cultural (which does not make it less “real”), but it probably is partly biological….  I see nothing wrong with wanting to have both experiences. [3]

An opponent of sex selection for family balancing can argue that good parents–whether prospective or actual–ought never to prefer, favor, or give more love to a child of one sex over the other.  For example, a morally good and admirable parent would never love a male child more than a female child, give the male more privileges than a female, or give a female more material things than a male simply because of sex or beliefs about the child’s “proper”gender.  A virtuous and conscientious parent, then, ought not to think that, or behave as if, a child of one sex is better than one of the other sex, nor should a good parent believe or act as if, at bottom, girls are really different than boys in the ways that truly matter.

“Sex selection is at least strongly ethically suspect, if not outright wrong”

The argument in favor of sex selection for family balancing has to assume that gender and gender roles exist and matter in the lived world.  For if they did not, then no reason would exist to differentiate the experience of parenting a male child from that of a female.  However, it is precisely the reliance upon this assumption to which the opponent of sex selection objects: accepting–and perpetuating–gender roles inevitably both harms and wrongs both males and females, although females clearly suffer much more from them than males.  While some gender roles or expectations are innocuous (e.g., men don’t like asking for directions), the overwhelming majority (e.g., males are–and should be–aggressive, women are–and should be–self-sacrificing) are not.  Consequently, given that sex selection is inevitably gendered and most gender roles and expectations restrict the freedom of persons to be who they wish to be regardless of gender, sex selection is at least strongly ethically suspect, if not outright wrong.

[1]  Steinbock B. Disability, prenatal testing, and selective abortion. In Parens E, Asch A (eds): Prenatal Testing and Disability Rights 2000; Washington DC, Georgetown Univ. Press: 108-123.

[2]  Ethics Committee of the American Society for Reproductive Medicine. Sex selection and preimplantation genetic diagnosis. Fertility and Sterility 1999; 72(4): 595-598.

[3] Steinbock B. Sex selection: not obviously wrong. Hastings Center Report 2002; 32(1): 23-28.

Watch: “Designer Babies” Ethical? L.A.’s Fertility Institute Says Prospective Parents Can Choose Physical Traits, Not Just Gender, from CBS NEWS:

Questions
1. Is it ethical to use preimplantation genetic diagnosis to select the sex of your child?
2. Consider the arguments presented about PGD and the ethical issues it poses in regards to disabilities. Does PGD reinforce a message about the disabled that, as disability activists claim, “negatively affects existing disabled people and fosters an increase in the oppression and prejudice from which they regularly suffer”?
3. In the video above, the doctor interviewed named Dr. Steinberg says, “Of course, once I’ve got this science (of PGD), am I not to provide this to my patients? I’m a physician. I want to provide everything science gives me to my patients.” Do you agree with Dr. Steinberg’s reasoning? Why or why not?

“Help loving couples conceive a child! Seeking egg donors with a clear health history, GPA 3.6+ and above 1350 on SAT.  Must play a musical instrument.  $10,00 Compensation.”

Have you seen an ad like this in your local college newspaper?  Chances are if you leaf through the classified sections of any elite university, you’ll find one just like it.  The advertisements, placed by couples or agencies looking for women to donate their eggs to be used to help couples conceive through In Vitro Fertilization, appear in college classifieds across the country.  They are notoriously featured at Ivy League schools, often targeting high achieving women with superior grades and test scores, offering anywhere from $5,000 to $50,000 for highly qualified donors.  Many call for specific qualities in their donors:  “Donor ideally has artistic skills, as intended mother is a talented oil painter and piano player,” reads one.

The internet has opened the door for other opportunities to advertise as well.  Countless private donor agencies advertise on websites, on Craigslist, and even on Facebook.  Just the other day, this add appeared on the side bar of my Facebook page:

Clicking on it brought me to a site for “superdonors”, which specialized in brokering transactions with “elite” egg donors like actresses and models:

I found out it’s no mistake that these ads appear on college campuses and are targeted to students on Facebook. A representative from Tiny Treasures, an egg donor agency, said:

“We have found that targeting [college] populations is likely to attract young, bright and responsible women who would be ideal prospective donors.”

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So what ethical questions are raised by the marketplace that has arisen for egg donors? To me, there seem to be a variety of factors to consider:

1) Should couples be able to specify particular talents and attributes in egg donors?

Many of these advertisements ask for specific characteristics in their donors, not only background health and psychological examinations, but certain ethnicities, SAT scores, GPAs, athletic abilities, and other special talents.  The fee offered—which can vary significantly– is often conditional on meeting these requirements.

The Yale Daily News wrote about one donor agency that, like “superdonors”, pays higher fees for more desirable donors:

“In a process akin to that of college admissions, Tiny Treasures requires all prospective donors to mail copies of their SAT scores and college transcripts with their applications, both of which have direct bearing on the amount of compensation received. The agency suggests first-time donors receive between $2,000 and $5,000, but students who qualify as “Extraordinary Donors” — those with SAT scores above 1250, ACT scores above 28, college grade point averages above 3.5 or those who have attended Ivy League universities — receive between $5,000 and $7,000 for their services.”

Asian donors are also highly targeted, as are Jewish donors.

Is it ethical for couples and/or agencies to specify traits, or is this a form of immoral eugenics? Should a couple be able to ask for a clear health history, but not high intelligence? A particular ethnicity, but not certain physical attributes?  In the marketplace for egg donors, is it ethical to base the quantity one pays on the so-called “quality” of the product?

The second question to consider is what role money plays in recruiting women to donate their eggs:

2) Does offering large sums of money constitute undue financial inducement?

Some bioethicists argue that offering such high fees to donors –ranging anywhere from $5,000 to over $50,000–is “coercive” and is unethical because it constitutes “undue inducement” of young women. Targeting college campuses takes advantage of trying to attract students who are in debt or otherwise financially strapped, where a sum of thousands of dollars could seem very appealing for a student who has student loans, is saving up for graduate school, or is looking to contribute to her savings. One donor writes,

“(When I was in graduate school) I found myself desperate for a few thousand dollars…I was sick and tired of being poor, demoralized from graduate school and the harsh criticism that goes with it, and I desperately wanted to get on with my life. I had seen ads in the free entertainment newspaper paying “$3,000 for Egg Donors” I was only making $10,000 to $12,000 a year, so this seemed like a fortune to me. And why not make money from something I wasn’t using?”

Though agencies report screening out women that are donating for purely monetary reasons, compensation, to be sure, plays a critical role in incentivizing donations.  Since the recession has hit, for example, egg donor rates have increased by as much as 40%.

But bioethicist Laurie Zoloth feels that donating eggs should be done free of cost, because providing financial compensation creates a slippery ethical slope:  “Whenever society starts to pay for relationships that are traditionally done with altruism and generosity within families, it raises the issue of whether there is anything that is not for sale.”

Eric Cohen, in his article, Biotechnology and the Spirit of Capitalism, echoes, “What we should most fear about biotechology’s transformation of modern capitalism…(is that) we will come to believe that bio-capitalism can sell us everything we desire, and thus come to accept that everything is for sale.”

The issue of compensation has become important in the area of research where, as Bioethicist Douglas Melton says, “The lack of compensation has meant it’s been nearly impossible to get enough eggs.”

But New York State recently passed a law to allow taxpayer-funded researchers to pay women for donating their eggs, stipulating up to $10,000 in compensation, which researchers believe is an important step in encouraging donations. Allowing compensation will encourage women to donate their eggs to research who wouldn’t have done so otherwise if the money had not been offered, and thus increase opportunities for research.

“We want to enhance the potential of stem cell research,”said David Hohn, vice chairman of the Empire State Stem Cell Board. ”If we are going to encourage stem cell research as a solution for a variety of diseases, we should remove barriers (to research) to the greatest extent possible.”

The questions are, is it ethical to use money to incentivize women into donating their eggs?  Is there a difference between compensating a woman for donating eggs to be used for IVF, and for compensating women for donating eggs to be used in research?

The issue of whether women should be compensated for egg donation inevitably prompts a more fundamental question at the heart of this discussion: What is the moral status of an egg, and how does that factor into what price, if any, can be placed on it?

3) What is the value of a human egg?

Is there a morally significant difference between donating blood and donating an egg? If so, what is it?  Opinions on the status of a human egg vary widely.

Harvard Business School Professor Debora Spar, author of “The Baby Business,” is against allowing compensation for donor eggs, telling USA Today simply, “We are selling children.”

But others featured in the same article don’t have ethical qualms with paying for eggs. Kristen, a UC Berkeley student and two time donor, says she donated with few moral concerns: ”What makes a child your child is that you raise it,” she says. “(My eggs) are just DNA.”

Many agencies get around this ethically complicated issue of “buying eggs” by claiming that the money is not paying for the eggs themselves, but for the trouble of going through the hormone injections and cycle to donate them.

One donor agreed: “I am going through injections daily and all sorts of medication (to donate my eggs).  I should be compensated.”

Bioethicist Ronald Green echoes, “We pay for participation in research that has risks associated with it for other procedures. So why not this?”

Do you agree with Debora Spar that paying for donor eggs constitutes selling children, and is therefore immoral? Or are eggs, like Kristen believes, “just DNA”?   Are they somewhere in between?

The final issue that stands out to me is to consider the way in which these advertisements are presented, and what role that plays in influencing the decisions of potential donors.

4) Whose responsibility is it to patrol these advertisements?

Psychologist Hilary Hanafin from the Center for Surrogate Parenting and Egg Donation said that college students are vulernable targets: ““Being an egg donor is a big decision. It’s not like being a blood donor, and a 21- or 19-year-old undergraduate probably doesn’t have the capacity to understand what she’s getting into.”

A student donor interviewed on the blog Ivygate who answered an egg donor ad conveyed similar sentiments:“ I don’t think young women think long and hard about the emotional risks. Try to imagine not how you feel at 19, but how you’re going to feel at 29.”

The physical risks, in addition, can be significant, and may be downplayed by these advertisements.  Some advocacy groups take issue with this lack of attention to the risks.  One campaign on Facebook states,

Given these concerns, should college newspapers and Facebook refuse to run these ads? Should there be limits on where and to whom these advertisements should be targeted?

In closing, there are a variety of ethical questions raised by this topic.  Should people be allowed to specify certain traits in their donors, and compensate them based on those traits?  What role does the sum of money offered to donors play in motivating donations, and is this unethical?  What is the moral value of a human egg, compared to the “market” value ascribed in these situations?

Listen to the following NPR podcast, “Egg Donation and the Free Market” (12:44) for two interviews with former egg donors.

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Watch a CNN Video, “Egg Donors On The Rise”, here:

Questions:

1) Is it ethical to pay money for donor eggs for research or for use in In Vitro Fertilization?  If so, how should the price be determined?

2) Is targeting students in college newspapers and on Facebook unethical?  Should college newspapers and Facebook remove these ads from their classifieds?

3) Consider the following quote from Eric Cohen’s Biotechnology and the Spirit of Capitalism: “The new commerce of the body…promises perfection, not progress; and it heeds no limits, treating the sacred and profane as indistinguishable objects for sale, ruled only by the amoral law of supply and demand.”  Should we allow market principles to dictate what is permissible and what is not with technology, or should we invest in drawing a strong moral line on certain practices? When it comes to reproductive technologies, where should that line be?

Leave your thoughts in the comments section below!

It is undeniable that medical technologies have saved countless lives and contributed to great advances in medicine.  But famed integrative medicine doctor Andrew Weil takes the view that medical technologies have drawbacks that are not often acknowledged.  He says:

“Technology has a shadow side. It accounts for real progress in medicine, but has also hurt it in many ways, making it more impersonal, expensive and dangerous. The false belief that a safety net of sophisticated drugs and machines stretches below us, permitting risky or lazy lifestyle choices, has undermined our spirit of self-reliance.”

Is Dr. Weil correct that technologies have “undermined our spirit of self-reliance”?  In general, in what ways has technology aided the practice of medicine, and in what ways has it inhibited it?

In addition, what are some of the ethical issues that arise from biotechnology?  For example, how will genetic testing and genetic manipulation shape the future of health and our society, and what moral questions are raised?  At what point, if any, should we say, “this far, but no further” when it comes to technological interventions to treat and cure diseases?

In her article, “A Framework for Thinking Ethically About Biotechnology”  Dr. Margaret McLean, director of Biotechnology and Health Care Ethics at The Markkula Center for Applied Ethics explores an important theme in the ethics of technology: considering the moral questions that arise from a technology before it becomes integrated into society.

“When considering ethical reasons for our actions,” she says,  “it is prudent to avoid “the Dolly effect,” that is, attempting to slam the ethical door well after the sheep has scurried away. The unanticipated arrival of new biotechnologies—from cloning to xenotransplantation—leaves the public, and the scientific community, without a framework for considering the attendant ethical issues. As we quickly learned after Dolly’s birth announcement was published in the New York Times, paying close attention to the direction biotechnology is headed is infinitely better than potentially overreacting once it gets there. To avoid the Dolly effect, the biotech community must initiate ethical discussions within itself and with the wider public.”

She continues with a framework for the important questions we must consider:

“Ethics is about questions: about who asks, what they ask for, and how we as individuals and communities respond. In reference to biotechnology, what questions should be posed? What aspects should be considered?

Along with the “golly wow” response to biotech innovation, we must ask, What are the personal and social impacts of biotechnology? What are its potential impacts on our values, our virtues, and our relationships? Does a particular application of biotechnology protect or endanger human or individual rights? Are the benefits and burdens distributed fairly? Does biotechnology advance or impede the common good? What are the risks, burdens, and benefits? On whom do they fall? How are they distributed? What is an acceptable way to achieve a given benefit? May we do anything, as long as the outcome is good on balance? Or are there limits on what we do, even in the name of human health? And, what—or whom—have we not thought about?”

Check back to the blog for discussions on these topics.

The Technological Citizen is a forum to explore and exchange ideas about the issues that arise from modern technologies. A wide variety of topics will be explored, including the ethics of cognitive enhancement, genetic testing, and biotechnologies, as well as the way in which technology impacts our relationship with other people, the environment, and ourselves.

Postings will fall under five basic categories:

Technology and Society
Technology and The Environment
Neuroethics
Ethical Issues in Health and Biotechnology
The Future of Technology

If you are interested in seeing all the posts on one particular topic, please click on that topic heading under “Categories”.

Thanks for checking out the blog! I look forward to hearing your ideas about these topics.