THE PROMISE AND PERIL OF COSMETIC NEUROLOGY
“Most of us would love to go through life cheerful and svelte, focusing like a laser beam at work and enjoying rapturous sex at night.”
When it comes to self-evident truths, you’d have to comb through a lot of back issues of Nature Neuroscience to beat the one Martha Farah posited in its November 2002 edition. In academic terms, it was a little outside of the Penn psychologist’s area of expertise. Farah, the Walter H. Annenberg Professor of Natural Sciences and director of Penn’s Center for Cognitive Neuroscience, was better known for her work on the neural underpinnings of vision, reading, and face recognition [“The Fragile Orchestra,” March|April 1998]. But her aim in this paper wasn’t to delve into sexual performance or laser-like focus at the synapse level. It was to answer a seemingly simpler question: So why don’t we go ahead and do it?
After all, there were pills on the market designed to bring about each condition. Viagra and Prozac were only the two best known. “In normal individuals,” Farah observed, Ritalin and Adderall “induce reliable changes in vigilance, response time and high cognitive functions, such as novel problem-solving and planning.” An experiment on a different drug, belonging to a new class of compounds known as ampakines, she added, found that it improved the performance of healthy human subjects on several memory tests.
What’s more, trends suggested that next-generation drugs targeting those and other areas might vanquish the worries that have traditionally discouraged healthy people from taking pills. “Until recently,” Farah wrote, “psychotropic medications had significant risks and side effects that made them attractive only as an alternative to illness. With our growing understanding of neurotransmission at a molecular level, it has been possible to design more selective drugs with better side-effect profiles.”
Around the time Farah became interested in the ethical implications of this, Anjan Chatterjee started contemplating the practical ones. As little as five years earlier, when decisions around drug prescriptions rested more or less exclusively with doctors, they may have been less intimidating. But as any physician could have told you, those days were over. The FDA’s 1997 decision to allow direct-to-consumer advertising of prescription drugs, coupled with the proliferation of medical information on the Web, had created a new kind of patient, one who came to the doctor armed with specific ideas and requests. Chatterjee, a practicing neurologist and professor of neurology at the School of Medicine, knew how this dynamic could drive demand for drugs to treat illness. A drug that promised a superior alternative to normality, he intuited, might change the practice of neurology in a more profound way.
This past April, Chatterjee laid out a hypothetical scenario drawn in part from his experience seeing patients whose concerns sometimes straddle the line between therapy and augmentation. The occasion was a media seminar that basically served as a sneak preview of the Center for Neuroscience and Society, which opened in August with Farah as its academic director (see sidebar on page 34). Chatterjee is one of the associate directors. He shared a clinician’s view of our cognitive future. It closely followed one he’d outlined in the Journal of Medical Ethics, which (taking the liberty of compression) went like this:
A well-to-do middle-aged executive walks into my clinic complaining of memory lapses that, upon further examination, seem to stem from stress or mild depression. I prescribe a selective serotonin reuptake inhibitor that makes him feel quite well and restores his professional performance. After a while he comes in again, this time complaining about the frequency with which the right word for a sentence seems just beyond the tip of his tongue. I suggest a cholinesterase inhibitor, explaining that the FDA doesn’t approve it for such a use, but that it may help. It does. Now he begins to think more expansively. His company is vying for a contract from the Saudi Arabian government, and he thinks learning Arabic will give him an edge over his competitors. I point out that there’s some data that amphetamines improve neural plasticity, so that combining one with a crash course in the language might help him learn it more quickly. Excited about the plan, he leaves for Saudi Arabia—with an Ambien to help him rest on the plane and some modafinil to make him alert when he lands—impresses the royal family with his Arabic, and comes home triumphant with the contract in his hand.
As someone who went into medicine to treat the sick, Chatterjee is plainly unsettled by this prospect, which he has dubbed “cosmetic neurology.” But he thinks it’s inevitable, and that now is the time for clinicians to begin contemplating how their roles may change in the face of “patients” whose essential complaint is that they’re all-too-ordinary. Chatterjee thinks cosmetic neurology is likely to edge into mainstream acceptability much the way cosmetic surgery has. Moreover, it will be harder to belittle someone for getting, say, a memory enhancement than a nose job or a tummy tuck. People will just come to see such things the way Chris Miner sees modafinil—as something that’s “as much a part of your tool kit as a graphical calculator and a notebook.”
To be sure, the pharmaceutical industry is a long way from cramming Arabic fluency into a capsule. Even the notion that an amphetamine like Ritalin constitutes a meaningful learning aid flies in the face of evidence that its effects are probably modest at best for people who are already functioning at a high level. But Chatterjee points out that in some settings, even modest effects can have outsized impacts.
“To give you an example, I was giving a talk about this in a graduate seminar in the bioethics program, and there was one student who objected to my saying that this was an issue,” he recounted. “Her feeling was that since the advantages [of cognitive-enhancing drugs] were so small, this was never going to be a really big deal. Before I could even answer her question, there were three other students in the seminar who objected. It turned out all three students were in law school. And their immediate point was that, to them, what they cared about was getting a decent clerkship that summer, or an internship at a prestigious law firm. And that any little advantage that got them into that would have really long-term consequences.”
What mainly worries Chatterjee and Farah is that the present drugs of choice for American undergraduate users—primarily Ritalin and Adderall, which are the most widely available on campuses through legitimate prescriptions for ADHD—carry substantial risks.
“The pills that people are using,” Farah says, “including students at Penn and a lot of other colleges, are not ideal cognitive enhancers. Probably the biggest drawback is that they are addictive. It’s not to say that a student who occasionally uses some illegally obtained Adderall to get a last-minute term paper written is necessarily going to become addicted, but they are running a risk, and, sad to say, a certain fraction of people who use them will end up addicted.”
If and as cognitive-enhancing drugs become safer, however, Farah believes that many of the other objections that have been raised to them will prove unconvincing.
One of the most common is that using them amounts to cheating, or a way to “gain without pain,” as Farah puts it. But she finds this argument wanting in a society that’s “full of shortcuts to looking and feeling better,” and which doesn’t begrudge vegetable haters their vitamin supplements, or college applicants their Kaplan test-prep courses.
Moreover, a drug like modafinil really isn’t a shortcut at all, but a way to extend and intensify effort—which is generally lauded in our society. As Chris Miner told me about his Wharton workload, “If I’m feeling lazy, I’ll sleep six or seven hours a night. Otherwise I’ll sleep four hours a night. And if I only sleep four hours a night I’ll use modafinil.”
Of course this raises another question. What if everyone else in your firm—or your kid’s classroom—elects to follow the path Chris Miner has chosen? You may feel you have no choice but to follow suit, simply to meet a standard of normalcy that has been revised sharply upward.
This presents a thorny challenge, but again, perhaps not an unprecedented one in a world where round-the-clock BlackBerry vigilance has become a baseline job requirement in some fields. “Clearly coercion is not a good thing,” Farah allows. “Yet it would seem at least as much of an infringement on personal freedom to restrict access to safe enhancements for the sake of avoiding indirect coercion of individuals who do not wish to partake.”
Farah and Chatterjee have also weighed the issue in terms of distributive justice. Presumably cognitive-enhancing drugs or devices would be more available to the haves than to the have-nots, potentially exacerbating the gulf between them. But Americans, both note (if with a measure of unease), have proven to be unusually tolerant of such inequities. And besides, the advantage conferred by 200 milligrams of modafinil is probably far smaller than the benefit of, say, private schooling.
But isn’t there something different about an advantage that actually changes the chemistry of your brain?
“That’s not so clear,” Chatterjee replies. “Think about being in a place where you have decent nutrition versus a place where you don’t, or growing up in an environment where you feel safe versus one where basic safety is an issue and life is full of stress. Those things have direct impacts on neuronal organization and neural structure [see sidebar on page 36]. What makes it qualitatively different? I think as you keep going down the line, it becomes harder and harder to say.”
When I later put the same question to Farah, she toasts it with a cup of coffee, her own cognitive enhancer of choice. “To the extent that there are problems with this idea of enhancing your brain with pharmaceutical products, the problem surely is not that it’s artificial—that it’s changing your mental state by ingesting a substance—because clearly we do that all the time.”