Enhance your mind

Mind altering drugs have been used for millennia, but until recent decades their use has largely been recreational. Alcohol has a history as long as civilisation and is even used by other primates, and the quest for opium has had a great historical impact. Now drugs designed for medical use have begun to be used by healthy people to enhance experience, intellect, and ability. This poses novel ethical challenges.

Here enhancement is defined as “interventions designed to improve human form or functioning beyond . . . good health.”^w1 This is a simplification and the subject of considerable discussion but is suitable for our introduction to the topic.^w2

The latter half of the 20th century saw the beginnings of modern neuroscience and psychiatry. These disciplines have largely focused on developing treatments for neurological disease, but many of the treatments developed also have profound effects on the healthy brain. Until recently the negative attributes of most prescribed psychotropic drugs ensured non-medical use remained limited, but newer agents are finding a wider audience as the balance between benefits and side effects shifts.

Get a new personality

To date the popular imagination has largely been captured by fluoxetine, the prototypal selective serotonin reuptake inhibitor (SSRI), better known as Prozac. Thanks to marketing and media coverage it has become a household name, and prescriptions of fluoxetine and similar drugs for the treatment of depression have increased massively. This is in part thanks to a safer profile than for older tricyclic antidepressants but also likely to be because of public pressure on prescribers. According to the UK Office for National Statistics, prescriptions of antidepressants rose from 9 to 24.3 million between 1991 and 2001, and this rise looks set to continue. As the range of pathology for which these drugs are used increases, they will inevitably become prescribed for conditions previously considered normal parts of personality and experience, such as minor depression.

Antidepressants are not simple mood enhancers, however; they have multiple subtle effects on the healthy mind. Several papers have shown that a short course of SSRIs reduces the impact of anxiety and fear on the psyche while increasing the relative weighting of positive experiences.^w3 There is also an effect on personality, increasing social interaction, and reducing aggression.^w4 These changes occur in days and without an appreciable change in mood.

Society must decide whether the use of antidepressants by a healthy person is acceptable. It has long been appreciated that often when intoxicated with alcohol people are “not themselves,” but this common scenario is usually brief. Few people live life in a state of intoxication, and addiction in this minority makes cessation difficult. Excessive alcohol consumption is frowned upon by society because of the harmful effects to the consumer and to other people. A person who takes antidepressants would have an altered mind with no overt outward signs, and yet the absence of physical addiction makes this readily reversible. Non-medical use of SSRIs enables people to alter their natural personality by deciding to take a pill. This could have a profound impact on interpersonal relationships: imagine trying to interact with a friend or acquaintance whose personality is to an extent determined by their latest pill. With the foundations of the individual so variable we face the “problem of authenticity”: who is it you fall in love with? And if we can find peace and happiness in a pill will we feel the need to fall in love or turn to religion?

These changes can be wrought today with drugs designed for a medically valid purpose. As public awareness and demand grows, drug companies may start to develop agents specifically to alter aspects of personality. Although in the short term it will be ethically difficult to test these drugs, the future may see the use of drugs not just to treat the psychiatric diseases of today but also to suppress undesirable tendencies and individualism. This may become manifest in “cosmetic psychiatry,” turning us into happy consumers of Aldous Huxley’s Brave New World.

Although the suppression of undesirable emotions may seem advantageous, at what point do we suppress the role that these emotions play in the rich experience of being human? Without this tapestry, life would be dull, and we would have difficulty identifying with the emotions of others.

Sharpen your mind

Another class of prescription drugs finding a growing consumer base are stimulants such as methylphenidate (Ritalin). Commonly used to treat attention disorders in children, amphetamines also have a long history of recreational use. Non-medical use of stimulants is now moving into the mainstream as a way to boost personal productivity.

Studies at US universities show a small but sizeable proportion of students who use stimulants off label. Not surprisingly this use often correlates with other high risk behaviour, such as smoking or binge drinking. Of more concern is stimulant use nearing 25% in universities with competitive entry requirements, especially at the most prestigious schools in the north east of the United States.^w5 Stimulants are also sanctioned for use by military forces to improve the performance of soldiers.^w6 Anecdotal evidence indicates that such practices are becoming more common in academia and medicine. The BMA recently highlighted the problem,^w7 especially with regard to unknown long term health risks, and this report received coverage in national press, including an article in the Guardian.^w8 This article says that the use of drugs such as methylphenidate and modafinil are widespread among doctors and undergraduate medical students in Britain, although we would contest this from personal experience.

Such a situation may, at first glance, seem inherently wrong, but as I write I am enhanced by the cup of coffee I am drinking. The use of caffeine as a stimulant in our society is widespread and common. Although caffeine occurs naturally in some products, it is now deliberately added to many drinks specifically for its stimulant effect. The use of more potent prescription stimulants is, therefore, difficult to reject on a logical basis. But precedent is set by a classification of the illegal drugs available today that is based on little evidence or logic.^w9 Many of the misused substances are, of course, legally prescribed and misused off license. In general, legislation tends to trail behind technological advance, and how it will adapt to these challenges is beyond the scope of this discussion.

Plasticity people

Even without drugs we all use enhancement. Every experience alters the neural connections in our brain, making some more potent and suppressing others, in what has become known as plasticity. Education is simply a way of exploiting this process to produce an enhanced result. As readers of the Student BMJ we have all spent many years enhancing ourselves to become better doctors.

If you judge a society by how it treats its lowest then pharmacology may find a legitimate role as an adjunct to education in improving society as a whole. Enhancing drugs could allow the least gifted people to keep up in an accelerating world, levelling the playing field for people with less able genotypes. Such a change would likely be resisted by the intellectual elite, although this position is hard to justify.

Pharmacological enhancement at the opposite end of the intellectual scale is also a double edged sword. In a competitive employment market the pressure to take drugs to compete is undesirable, as in sport. Again this must be balanced against the potential benefits to society. The impact of pharmacology on our intellectual performance is also unclear, and it may be that access to high quality education and other resources remains the limiting factor for most people. Designer drugs are likely to be expensive and unavailable to the people who would benefit most.

Hooked on computers

In addition to pharmacology, microelectrode arrays that link to computers may also eventually provide enhancement, although experiments to date have been basic.^w10 Advances will challenge the notions of ownership: what work is our own if enhanced by chemicals or computers? This problem may avoid debate because any change is likely to be gradual and may be accepted by default. Already, cochlear implants can be wired into the brain to correct sensorineural hearing loss, and thought translation devices are finding use in paralysed patients.^w11 Whether the use of such innovations to reduce pathology is true enhancement of physiological function is debateable.

Computers and the internet have become increasingly central to our lives in the past decade, facilitating rather than replacing what humans can do. As devices continue to get smaller and increase in power, the search for more efficient interfaces between people and machines becomes an increasingly important challenge. New mobile phones have perfected the touch screen, and voice command is becoming widespread in our cars. Is complete neural integration the logical conclusion?

The rapidly advancing discipline of neuroscience will result in opportunities to alter and enhance our character. Some of the ethical dilemmas have been raised here, and others will arise that cannot be predicted. Public and medical awareness is essential so that we are prepared to overcome the challenges before they become pressing and our hand is forced to substandard, insufficient response.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References w1-w11 are on student.bmj.com.

1. w1 Juengst ET. What does enhancement mean? Enhancing Human Traits: Ethical and Social Implications Georgetown University Press 1998
2. w2 Savulescu J. Justice, Fairness and Enhancement. Ann NY Acad Sci 2006:1093:321-338
3. w3 Harmer CJ, Shelley NC, Cowen PJ, Goodwin GM. Increased positive versus negative affective perception and memory in healthy volunteers following selective serotonin and norepinephrine reuptake inhibition. Am J Psychiatry 2004;161(7):1256-63.
4. w4 Knutson B, Wolkowitz OM, Cole SW, Chan T, Moore EA, Johnson RC, et al. Selective alteration of personality and social behavior by serotonergic intervention. Am J Psychiatry 1998;155(3):373-9.
5. w5 McCabe SE, Knight JR, Teter CJ, Wechsler H. Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey. Addiction 2005;100(1):96-106.
6. w6 Kenagy DN, Bird CT, Webber CM, Fischer JR. Dextroamphetamine use during B-2 combat missions. Aviat Space Environ Med 2004;75(5):381-6.
7. w7 BMA Ethics Department. Boosting your brainpower: ethical aspects of cognitive enhancement. BMA November 2007
8. w8 Katharine Hibbert. Ways to make you think better. The Guardian 8th November 2007
9. w9 MacDonald R, Das A. UK classification of drugs of abuse: an un-evidence-based mess. Lancet 2006:368:559-61
10. w10 Warwick K, Gasson M, Hutt B, Goodhew I, Kyberd P, Andrews B, et al. The application of implant technology for cybernetic systems. Arch Neurol 2003;60(10):1369-73.
11. 0w11 Hinterberger T, Neumann N, Pham M, Kűbler A, Grether A, Hofmayer N, Wilhelm B, Lor H, Birbaumer N. A multimodal brain-based feedback and communication system. Exp Brain Res 2004:154:521-6

       

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