Cognitive Enhancement

Social and Public Policy Issues

Robert H. Blank

• Publisher: Palgrave Macmillan
• Year: 2015
• ISBN:
  9781137572486
• Topic: Philosophy
• Subtopic: Ethics & Moral Philosophy

Rapid advances in cognitive neuroscience and converging technologies have led to a vigorous debate over cognitive enhancement. This book outlines the ethical and social issues, but goes on to focus on the policy dimensions, which until now have received much less attention. As the economic, social and personal stakes involved with cognitive enhancement are so high, and the advances in knowledge so swift, we are likely to see increasing demands for government involvement in cognitive enhancement techniques. The book therefore places these techniques in a political context and brings the subsequent considerations and divisions to the forefront of the debate, situating their resolution within the milieu of interest group politics. The book will provide a starting point from which readers can develop a balanced policy framework for addressing such concerns.

1

Introduction to Cognitive Enhancement

Abstract: After discussing what cognitive enhancement (CE) is and how it differs from therapy, this chapter will provide an overview of a range of nootropic drugs, devices and procedures that are, or are proposed to be, used for enhancement. Those covered include: methylphenidate; modafinil; amphetamines; beta-blocking drugs such as propranolol; donepezil; brain games; neurofeedback; transcranial direct current stimulation; transcranial magnetic stimulation; deep brain stimulation; and brain-computer interfaces (BCI). It then summarizes the latest scientific data on the efficacy of these interventions. It also includes an analysis of the current prevalence of CE use.

Blank, Robert H. Cognitive Enhancement: Social and Public Policy Issues. Basingstoke: Palgrave Macmillan, 2016. DOI: 10.1057/9781137572486.0003.

Rapid advances in cognitive neuroscience and converging technologies have created a vigorous debate over cognitive enhancement (CE) (Saniotis, 2009; Cakic, 2009; Farah et al., 2014). Although there are strong opposing views over the ethics of enhancement, there is little doubt that such endeavors will proliferate in the coming decade. In a highly competitive society where the difference between winning and losing is measured in miniscule degrees, demand for any enhancement edge is inherently strong, driven by the high economic stakes of a thriving enhancement industry. Moreover, we live in an era dominated by forces that create ‘needs’ through captivating marketing of products promising a better life. Marketing of these products through the media and the Internet is already active and, absent regulation, will escalate. Despite the controversy over CE, therefore, it will be alluring to many individuals and democratic governments will be hard pressed to limit its use. As noted by Martin et al. (2011), although the debate over CE continues within the scientific community and among bioethicists, it has created the expectation of an inevitable increase in the pursuit of CE, that this widespread usage will change the way we live our lives and that the future will bring new ways of enhancing, controlling and reading the brain.

This book focuses on the public policy dimensions of CE and places a wide array of enhancement techniques in a social context. Since CE is likely to become more commonplace in the near future, it will progressively generate a range of policy issues. Importantly, since different interventions involve more or less risk to the user and vary in effectiveness, it is counterproductive to lump all potential new enhancement methods into one category (Coenen, 2008). The more intrusive and risky the procedure or drug, the closer the policy attention should be. There is also a need to balance the individual right to self-improvement with the numerous social costs that could arise. While enhancement technologies are in various stages of research and development and some are likely to have no real enhancement capacity, many observers stress the need for expanded research efforts (Bostrom and Roache; 2009; Dubljević et al., 2015). Meanwhile, as we will see later, the media tends to exaggerate the positive effects of CEs and downplay or ignore the negative effects (Partridge et al., 2011). Because the broader policy implications are extensive and touch many areas of human existence, these techniques must be scrutinized as to their impact on the individual and society as a whole. Any such dialog is likely to increase demands for some level of government involvement in enhancement techniques (Greely and Illes, 2007; Kulynych, 2007).

Among the many books on CE published in the last few years are Savulescu et al. (2009), Glannon (2011), Hildt and Franke (2013), Cohen Kadosh (2014), Muriithi (2014) and Knafo and Venero (2015). Although some have touched on public policy, most have focused on ethical or scientific issues. The move of CE to the policy domain alters the context by bringing to the forefront political considerations and divisions and placing the resolution of these issues in the milieu of interest group politics. This short book attempts to provide a start in developing a balanced policy framework for addressing these issues. After defining CE and providing an overview of its methods and prevalence in this chapter and reviewing the ethical issues and social context of enhancement in Chapter 2, the last two chapters of this book explicate the political and policy dimensions. Chapter 3 presents the range of policy options for CE and examines why it will be difficult to get on the policy agenda, especially in the U.S. Chapter 4 provides a preliminary framework for analysis of the various CE methods. Regulatory and research needs are emphasized.

Defining Cognitive Enhancement

At first glance, CE would appear to a casual observer to be a fairly straightforward concept. However, given the plethora of CE methods and the sweeping scientific, ethical, social and political issues they raise, it is soon obvious how complicated, and provocative, it actually is. While the line between enhancement and therapy is often hazy, many applications embody attempts to enhance human traits or performance rather than treat disease or promote health (Miller and Brody, 2005; Talbot, 2009). Because the distinction between therapy and enhancement is often difficult to discern in practice, it could even be argued that it lacks practical significance (Bostrom and Sandberg, 2009). According to Repantis and colleagues (2010), the term neuroenhancement refers to improvement in the cognitive, emotional and motivational functions of healthy individuals through drugs or other means. Singh (2005) adds that enhancement technologies are those treatments that improve human performance, appearance or behavior where such improvement is not medically warranted. De Jongh and colleagues (2008) distinguish among: (1) cognition-enhancing drugs used to improve short- and long-term memory or executive functioning that manages other cognitive processes and is involved in planning, cognitive flexibility, abstract thinking, and inhibiting inappropriate actions; (2) drugs that enhance mood and pro-social behavior; and (3) drugs that prevent the consolidation or reconsolidation of unwanted (traumatic) memories. To date, most attention has focused on the first use (Banjo, Nadler and Reiner, 2010). Neuroenhancement has also been termed cosmetic neurology (Chatterjee, 2007).

Cognitive Enhancement as therapy

In much of the literature, especially the scientific, CE is used to describe efforts to improve cognitive function by reversing or compensating for deficits in intellectual function that are found with most mental illnesses and neurological disorders (Forlini et al., 2013). In developmental disorders such as attention-deficit hyperactivity disorder (ADHD), drugs acting on the noradrenergic and dopaminergic systems, such as methylphenidate, are now in widespread use (Husain and Mehta, 2011). Similarly, for neurodegenerative disorders such as Alzheimer’s, Huntington’s and Parkinson’s diseases, acetylcholinesterase inhibitors and memantine have become standard treatments. Furthermore, a wide range of drugs are being assessed for CE in chronic mental disorders such as schizophrenia where cognitive deficits are separable from positive (e.g. hallucinations and delusions) and negative (e.g. blunted affect) symptoms, and because current antipsychotic treatments have little, if any, impact on cognitive impairments. For many patients with schizophrenia, cognitive difficulties are the main factor limiting rehabilitation and quality of life, particularly after clinical symptoms have abated (Turner and Sahakian, 2008). In some schizophrenics even small improvements in cognitive functions could help them make the transition to independent living.

Similarly, attempts to ameliorate cognitive deficits following stroke are being actively explored (Hsieh, 2015; Wang et al., 2014). Many stroke patients struggle with simple everyday activities that require concentration, memory, problem-solving and planning. Thus, the potential public health benefit of improving current treatments for cognitive disabilities in patients is clear. Long-term drug use is also associated with a wide-range of cognitive impairments, including many executive-control functions, response inhibition, working memory and sustained attention. Although there is relatively little research assessing the capacity of cognitive enhancement treatments to improve substance use outcomes via their modulation of cognition, various medications including modafinil, atomoxetine and methylphenidate are viewed as having promise in the treatment of addictions (Sofuoglu et al., 2013).

The term cognitive enhancement also has been used to refer to efforts to augment cognitive function among the healthy elderly. Cognitive decline and memory impairment accompanies age-related changes in the brain and could indicate the onset of dementia (Bibb et al., 2010), but many in the booming aging population without dementia worry about losing cognitive abilities and they represent a huge growing market for some enhancement products. Cognitive enhancement is viewed as a key strategy to slow the effects of aging on brain function and improve everyday functioning in multiple domains (Harvey and Keefe, 2015). Epidemiological evidence suggests advantages of the inclusion of cognitive training as a daily activity as a lifestyle intervention against cognitive aging (Strenziok et al., 2014). Many methods for enhancing neurocognitive functioning in healthy elderly populations, including the use of brain games, pharmaceuticals and stimulation methods, have been used (Taya et al., 2015). Although most of the reported positive effects of drugs and other approaches to enhancing cognition in these areas have been modest in magnitude overall and are highly variable across individuals, they have generated interest in CE, not only for patients with brain disorders, addictions or the elderly, but also for healthy individuals who want to increase cognitive function. Although it is very difficult to untangle cognitive therapies from CE, this book will focus on the more narrow use of the term as it applies to healthy individuals.

CE here, then, is achieved when cognitive abilities are improved above what is considered to be ‘normal-range’ functioning for human beings. The resulting dichotomy between traditional therapy and enhancement, when drugs that have been developed for the treatment of diseases and disorders have applications outside of medicine for the enhancement of healthy individuals, however, causes problem with many physicians opposed to prescribing CEs, on the basis that these products do not treat any illness and are, therefore, outside the scope of medical practice (Banjo et al., 2010; Mendelsohn et al., 2010; Schelle et al., 2014; Bergstrom and Lynoe, 2008). Some physicians have reported that they would feel comfortable for those with cognitive disability to use CE products for treatment purposes, but that it is inappropriate for healthy individuals to be using such products (Franke et al., 2012). Where this distinction between ‘cognitively disabled’ and ‘normal functioning’ lies is unclear, and will likely become more ambiguous as our cognitive traits continue to be pathologized (Conrad and Horwitz, 2013; Coveney et al., 2011; Schanker, 2011).

Furthermore, it can often be difficult to categorically determine whether an individual is ‘normal’, or suffering from a psychiatric condition requiring treatment, because many psychiatric diagnoses present as spectrum disorders. If we are going to posit differences between treatment and enhancement, we need a clear conceptualization of the point at which treatment becomes enhancement which, in turn, hinges on the definition of normal (Turner and Sahakian, 2008). Given the slipperiness of the distinction, Savulescu et al. (2011) argue that instead of trying to determine whether certain drugs or certain of their effects constitute treatment or enhancement, it is more logical and useful to think of a continuum of wellbeing which can be increased or diminished by various interventions. Maslen et al. (2014), for instance, envision a sliding scale from interventions that are intended simply to sharpen a certain cognitive skill in a healthy person to those intended to relieve a person of pain or another burden that significantly affects his or her ability to pursue the normal range of activities.

As Nagel (2010) has noted, this growing and ever more finely-tuned capacity to tamper with normally-functioning neural systems raises a number of ethical questions about the boundary between traditional research/clinical practice and outright human enhancement. Moreover, Mehlman and Berg (2008) warn that the distinction between enhancement and health-oriented research is not a bright line. A working definition of CE is that it is an intervention that employs medical and biological technology to improve performance, appearance or capability. Often, an enhancement will place a person above the population norm, but this need not always be the case. If an individual started out within the normal range, for example, an improvement would be an enhancement even if it left the individual within the normal range. Moreover, the concept of ‘normality’, is itself elusive and may vary widely from place to place and time to time. One of the issues surrounding CE discussed in Chapter 2 is whether CE itself will alter the concept of normality.

Under the more narrow definition of CE used here, an enhancement does not aim to prevent, treat or mitigate the effects of a disease or disorder. In essence, then, it is defined as any improvement or extension of mental capabilities or performance in the absence of clinically defined illness (Schermer et al., 2009). However, the concepts of disease and disorder themselves are also hard to pinpoint, especially with the tendency to regard more and more health states as diseases and, thus, more interventions as treatments (Nagel, 2010). Invariably, there will be borderline cases and disagreement among observers. From a sociological perspective, the distinction between therapy and enhancement is difficult to uphold because the concepts this distinction is based upon (i.e. normal, health, disease, etc.) are so difficult to establish and variable over time (Ball and Wolbring, 2014).

Medicalization of CE

Cognitive enhancement is further complicated by medicalization (Coveney et al., 2011; Schanker, 2011). Over the past three decades in Western medicine, a vast medicalization has occurred where behavior and conditions become defined or treated as medical (Conrad and Horwitz, 2013). A physical, biological or psychological condition or behavior is said to be ‘medicalized’ when it is described within a medical framework, given a medical label as an illness or disorder or treated with a medical intervention (Conrad and Horwitz, 2013). According to Coveney and colleagues (2011), the pharmaceutical and biotechnology industries are said to have played a major role in redefining normal behavior and states as medical problems that warrant pharmaceutical treatment.

Frequently, medicalization of a problem is linked to the availability and profitability of a treatment for it, buoyed by a growing consumerist orientation to health care (Ableson et al., 2007). Reinforced by enthusiastic media reporting and direct-to-consumer advertising in the U.S., an increasing number of patients pressure their physicians to prescribe the drug, thus lowering the threshold where patients are deemed suitable to receive treatment for specific symptoms (Conrad and Horwitz, 2013). Moreover, Internet sites enable consumers to access CE products without the need to visit a doctor, illustrating medicalization via the application of a medical solution to an everyday problem without the direct involvement of medical professionals. While there is apprehension about the direction of current and future biotechnologies, the increasing use of these technologies in defining human beings is probably inevitable, primarily due to the medicalization of the human body in Western medicine which tends to view the human body as a machine (Saniotis, 2009).

More recently the term biomedicalization has been introduced to describe the transformations in medicine and of bodies through technoscientific interventions that are used not only for treatment but also increasingly for enhancement or optimization (Clarke and Shim, 2011). The customization of bodies through tailor-made medicines, technologies and cosmetic surgery, in addition to the proliferation of ‘lifestyle’ drugs, are viewed as marking the move away from medicine-as-therapy towards medicine-as-enhancement (Conveney et al., 2011). Within a medicalization framework, the term enhancement can be broadly translated as an ‘improvement’ to body, mind or performance: something which adds to, builds upon and extends one’s existing capabilities. However, in this view, every treatment can also be considered to be a form of enhancement (Synofzik, 2009) encompassing therapeutic as well non-therapeutic effects. ‘The medicalization thesis can thus be used to explain how, when viewed through a medical framework, human behaviours and cognitive states can come to be understood as abnormal and how new pharmaceutical technologies can then be positioned as legitimate therapies to normalize, correct or repair specific aspects of cognitive functioning. Medicalization, is then, linked to legitimacy of both the therapeutic target and the use of the technology to treat it’ (Coveney, Williams and Gabe, 2011). Using the concepts of medicalization and biomedicalization can help explicate how biomedical interventions can come to be legitimated for use by healthy people by shifting emphasis from treating illness to optimizing one’s life chances (Clarke and Shim, 2011).

For a new drug to be proven effective in clinical trials and gain regulatory approval, it must target a definable illness or disorder to measure improvements against. As a result, new diseases or disorders may be created in order to legitimize new medical treatments and interventions. This leads some to speculate that we live in a society where there is an ‘ill for every pill’ as pharmaceutical companies attempt to increase the markets for their products and legitimate consumption (Busfield, 2010). It has been argued that the rise in profile and availability of so-called lifestyle drugs is contributing to the pharmaceuticalization of daily life as consumers come to see such substances as ‘magic bullets’ to resolve their everyday problems (Fox and Ward, 2009). There are several documented cases of drugs developed to treat specific diseases that have crossed over from therapies to common usage for enhancement purposes where no medically-defined need can be identified. For example, the drug Ritalin, which is marketed as a treatment for ADHD, reportedly, is now widely given to children who do not qualify medically as ADHD sufferers and used by high school and college students as a study aid. Similarly, it has been claimed that there is already a significant amount of drug taking among academics with the goal of improving cognitive performance or stamina (Maher, 2008). Despite the limited amount of empirical evidence available, this demonstrates how, although pharmaceuticals might be developed as medicines to treat a genuine primary disease indication and accessed via medical professionals, their usage can extend far beyond the treatment of disease to become a means of enhancing various aspects of social life (Williams et al., 2011).

According to Barbara Sahakian, ‘The drive for self-enhancement of cognition is likely to be as strong if not stronger than in the realms of enhancement of beauty and sexual function’ because ‘we are a society that so wants a quick fix that many people are happy to take drugs’ (quoted in Talbot, 2009). For the time being, people looking for this particular quick fix have a limited choice of medication, but that will likely change given the economic stakes involved. New psychiatric drugs have had a way of creating markets for themselves. Disorders often become widely diagnosed after drugs become available that can alter a set of suboptimal behavior. One example is the emergence of a new disease and susceptibility category of mild cognitive impairment (MCI) (Williams et al., 2011). MCI is a label that is used to describe individuals who do not meet diagnostic criteria for dementia, but who exhibit some mild cognitive deficits and are thought to have a greater than normal risk of progressing to dementia. This example not only elucidates how blurry the boundaries between what is considered to be normal and abnormal cognitive functioning are and how these can shift over time, but also the new focus on risk and lifestyle as a valid site for biomedical intervention in the biomedical era (Coveney et al., 2011).

Technology fix mentality

Western culture, then, is predisposed toward progress through technological means. In our attempts to overcome disease and illness, we have always stretched the boundaries of intervention into the human body. In many ways, this continual expansion of our ...

Table of contents

• Cover
• Title
• 1  Introduction to Cognitive Enhancement
• 2  Ethical and Social Context of Cognitive Enhancement
• 3  Policy and Politics of Cognitive Enhancement
• 4  Framing Cognitive Enhancement Policy
• References
• Index