Performance Doping in Academia, Take 2

A recent commentary in Nature by Barbara Sahakian and Sharon Morein-Zamir discusses the ethical questions arising from the use of cognitive enhancing drugs to improve intellectual function in “normal” people. This follows a prior piece in Nature arguing that science-enhancing drugs may not be just acceptable but indeed laudable, which I covered previously. A couple of blogs are already on it, including Adventures in Ethics and Science (natch), Retrospectacle and Action Potential. [Update: 12/21/07: More from the Silverback , Corpus Callosum and Munger.] Commentary on the first two Borg blogs is already quite brisk. People seem to love discussing brain doping!

I’ll start with a disclaimer. I was holding off on this topic a little and I realize in part because of the conflict issues. Yet I’ve commented at AinE&S and Retrospectacle so that sort of pre-empts things and despite the direction my comments are going to go, some disclosure seems relevant. First, a minor issue, I am passing acquainted with one of the authors of the Nature commentary. Second, I have done some work that might be viewed as contributing to the “cognitive enhancer” literature. Not much, but my professional interests (for which I get paid, naturally) touch on this area of science. Third, I have consulted informally and formally (meaning I got paid) for BigPharma research units interested in developing cognitive enhancing drugs, broadly writ. Consider yourself warned.

We can rapidly dismiss what I see as the non-controversial aspects of the commentary. That is, the straw question raised, “Should adults with severe memory and concentration problems from neuropsychiatric diseases be given cognitive-enhancing drugs?“. The answer is simple, of course they should. Sahakian can perhaps be excused given that this is her life’s work. Further refinement to ask if cognitive enhancers should be used in children and adolescents is obviously just as absurd if we frame it as “Should appropriate, effective and safe medications be used to treat children and adolescents for medical indications?”. Duh, of course they should. Even if they do have side-effects. Take growth “stunting”, a serious theoretical concern with long-term stimulant treatment. Evidence to date suggests that maybe an inch or two lower adult height results (for Ritalin, see this, this, this, this). Take a side-effect like that and, rather than screaming “aaaauuughh, side effect!” ask which is better- a couple of inches shorter or a failed primary school experience? Which is more important for your child? As with much of modern medicine it is a question of tradeoffs. What positive clinical effects are more important than what set of side-effects. I fail to see the ethical implications.

Still, I will admit that the most interesting thing about fixing disorders with drugs is indeed the question of “side-effects” and “safety”. Interesting, primarily because our science to detect lasting toxic effects of acute and chronic drug exposure is not so hot. We’re trying, believe me. I find it a fascinating issue, myself. And even though I currently focus on so-called recreationally abused drugs, it is hairsplitting in the extreme to suggest that the issues at hand are conceptually distinct. The details, sure. But if someone takes amphetamine to get “high” or takes an amphetamine (Adderall is good old amphetamine, don’t let the “mixed amphetamine salts” crap lead you astray) to treat Attention Deficit/Hyperactivity Disorder or takes amphetamine (say, diverted Adderall) to improve academic performance, well, we still want to know the same things. “How much is too much?” to broadly generalize the essential scientific question. Still this issue has nothing to do with ethics. And I might mention, neither does the debate over how accurately we may be able to categorize individuals into ordered/disordered groups when it comes to mental disorders. This is important, yes, but it isn’t an ethical problem, these are empirical questions to be answered by your faithful servants, tax-payer funded scientists.

People such as Janet and Shelley seem to be under the impression that safety is relevant to the ethical considerations of using cognitive enhancers in “normal” people. Although when pressed Shelley and Janet each back up to suggest that safety and side effects are at least relevant to personal choice, if not the ethics per se. They each also seem to be under the impression (as do many of their commenters) that there is much more known, scientifically, about the “safety” and “side-effects” of our well accepted cognitive enhancers caffeine and nicotine than other compounds. To some extent, especially from the standpoint of broad spectrum use in human populations and the conclusions that might be drawn regarding very gross, population-level measures of side effects. On the other hand, because some legal compounds are so accepted, I’d argue that we know more specific scientific information about potentially brain-modifying effects of, say, amphetamine than we do about caffeine. Replace “neurotoxicity” with “cognitive” or other key word in those PubMed searches and you’ll find similar results. That is, commonly used, legal and accepted “safe” drugs are frequently less studied with modern techniques than one might otherwise wish because legal is sometimes equated with “uninteresting”. Despite a fairly significant caffeine addiction (disclaimer!) I really have little perspective on lasting detrimental cognitive effects. Compare this with what is known about lasting effects of alcohol and you’ll see how much we really don’t know. An absence of studies does not necessarily mean that caffeine is perfectly benign.

The original commentary then asks, in essence if it is “cheating” for otherwise normal people to use cognitive enhancers. The central consideration is that we’ve already crossed that Rubicon. Caffeine and nicotine being the primary examples. It is completely acceptable, particularly in the case of caffeine, to brag on use of this stimulant to confer unnatural and unfair advantage over the competition in academic performance. From undergrad, to grad to professordom. Any argument that tries to overlook or minimize this reality is completely bogus. “I wrote my last grant on Modafinil”, “I wrote my last grant at the local coffeeshop” and “I wrote my last grant on Adderall” should have precisely the same ethical implications. The legal status, common acceptance, route of administration of the compound, specificity of the compound, etc have nothing to do with the ethical question of “cheating” by taking a cognitive enhancing compound.

Finally we get to the “raising the bar” complaint mentioned in the Nature piece. This is also one of the primary arguments against sports doping and it is frequently cast in terms of one’s offspring. “If sports doping is permitted, this will mean that anyone who wants to play will be forced to take these drugs. Do you want your kid taking this stuff?” This always rings a bit hollow to me and particularly so in the case of putative cognitive-doping. In case it is news to anyone, the pinnacles of performance one reaches are related not just to some “natural” ability but also to choices made and actions taken in the pursuit of a given goal. If an athlete is totally coddled by their parents, allowed to focus almost exclusively on their cycling for example, nobody thinks this is “unfair” to the poor kid who has to work summer and school year jobs. Neither is it “unfair” that this coddled kid beats that kid who just refuses to train. “Oh”, you say, ” but the drugs are bad for your health”. Yes, and so is training on the bike for a Cat 1 or, particularly, a professional level of performance. Sure, the cardiac benefits might outweigh the risk of road rash, clavicle breaks, death-by-redneck-truck, etc but it isn’t risk free. The “raising the bar” critique for cognitive performance is no different.

• Is it fair that Professor Smith uses an alarm clock to get up one hour earlier than you do?
• Is it fair that Professor Jones has a doting spouse that takes on all the household and childcare responsibilities?
• Is it fair that Professor Brown is unmarried, unattached and just plain works like a dog around the clock?
• Is it fair that Professor Doe never exercises and eats crappy takeout food to maximize the hours at work?

All of these lifestyle choices might be viewed as entailing some degree of health, social or psychological risk in the pursuit of career performance might they not? Would you ever suggest these people were unethical or “cheating”? What difference does it make if Professor Armstrong chooses to use cognitive enhancing drugs?