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Are We Obligated to Make Ourselves More Moral and Intelligent? (Part One)
J. Hughes   Mar 13, 2014   Ethical Technology  

Most of the ethical discussion of the use of stimulant drugs without a prescription in education has been negative, associating their use with performance enhancement in sports and with drug abuse. But the use of stimulants as study drugs actually has few side effects, and is almost entirely applied to the student’s primary obligation, academic performance. In this essay I consider some objections to off-label stimulant use, and to stimulant therapy for ADD, and argue that there are ethical arguments for the use of stimulants, and for future cognitively and morally enhancing therapies, in education, the work place, and daily life.

In recent years, as the diagnosis of ADD has become more common, and increasing numbers of adults have begun taking stimulant medications as a treatment for ADD, or without a prescription as a study aid, there have been calls for stricter regulation of the diagnosis and the drugs. People have suggested that the treatment of ADD with stimulants is a conspiracy of pharmaceutical capitalists in league with dubious pediatricians, when the real cause of inattentiveness is allegedly a dysfunctional industrial era educational system obsessed with standardized testing. The alleged risks of the use by adults without prescriptions have been hyped, and the "users vilified as "cheaters" contributing to a pharmaceutical arms race.

I do not dispute the need to overhaul our dysfunctional approach to education, and some of the pressure to diagnose kids would be relieved by more personalized pedagogies. We also need to be protected from abusive workplaces that demand unhealthy hours of attentiveness. There is also, of course, an indisputable pressure on the part of the medical-industrial complex to medicalize our lives, and sell us drugs for our newly discovered maladies. On the other hand, it is also true that our predecessors had to bear levels of pain, illness, disability, depression and distractability that we now can avoid by the judicious use of the fruits of medical capitalism. We need to balance our critique of these social and economic problems with the acknowledgment that there may still be merit in some of the ways that parents and adults are using cognitive enhancing drugs.

So in this essay I'd like to take a different approach to the use of stimulants and cognitive enhancing drugs, with and without prescriptions, looking at their use through the several ethical lenses that are being applied in the emerging debates over cognitive and moral enhancement. The basic point I want to make is that the use of stimulants and other cognitive enhancing drugs can be warranted by our general moral obligations to exercise more self-control, and to be as attentive and intelligent as possible. In particular, I will argue, students have specific moral obligations to learn which can also legitimate their use of cognitive enhancement substances.

The Use of Stimulants in Education

First, it is important to note that stimulants of various sorts have been in use for thousands of years, and specifically have been used to enhance intellectual activity and moral self-control. The drinking of tea has a long tradition in Chinese culture, which celebrated its reputed beneficial effects for scholarly work and meditation. Confucius edicts say "Tea tempers the spirits and harmonizes the mind, dispels lassitude and relieves fatigue, awakens thought and prevents drowsiness, lightens or refreshes the body, and clears the perceptive faculties.” Buddhist monks were forbidden intoxicants, but drank a lot of tea to keep awake for meditation and rituals. The Japanese Zen tradition developed a tea ceremony which makes the making and drinking of tea itself into a meditation.

Evidence points to the widespread chewing of coca leaves in the Andes as far back as 8000 years ago, where it was believed to be of divine origin. Similarly Egyptians, Ethiopians and Yemenis have been chewing the stimulant qat plant for thousands of years, and in ancient Egypt it was believed to be an ingredient in a ritual to make the user into a god.

Coffee and coffeehouses have a long tradition in Arab and Turkish culture where they were hubs for entertainment and conversation, and were referred to as "schools of the wise." Sufis drank coffee to stay awake during their dervish devotions, and Pope John Paul II beatified the 17th century Franciscan friar that invented cappuccino.

Before the introduction of coffee, tea and chocolate into Europe the average European drank alcohol from morning until night. In the 17th and 18th centuries the coffeehouses became exciting hotbeds of learning, debate and reading, so that they were called "penny universities," since a cup of coffee cost a penny. In sharp contrast to the pacifying debauchery of the alehouses, coffeehouses were the key vector for the spread of Enlightenment ideas of reason, democracy and human rights, so much so that they came under political attack from monarchists.

Similarly the rise of the temperance in the United States in the 19th century attempted to impose some self-discipline on the enormous amount of alcohol American colonists consumed in the 18th century. Drunkenness was a common problem in nineteenth century homes and factories, and the consumption of coffee and tea as an alternative that boosted alertness and self-control was promoted instead.

In all these societies there have been some moralists who inveighed against the intoxicating effects or addictiveness of stimulants, from conservative Muslim scholars to Mormon elders, but it was with the invention of cocaine and amphetamines in the late 19th century that dopamine hijacking with stimulants became a truly widespread public health risk. Cocaine use began to spread in late 19th century, and after thousands of deaths a year were being attributed to it cocaine was banned in the U.S. in 1922. Amphetamines then took off when they began to be prescribed for all kinds of ailments in the 1930s, and were given a big boost when the US Army dispensed them liberally to soldiers in World War II. In the 1950s, amphetamines became popular on university campuses and in the counterculture. By 1962 amphetamines were so popular that Americans consumed an average of forty-three doses per person per year. Today, cocaine, crack, and methamphetamine are of course significant drugs of abuse and threats to public health.

So am I defending amphetamine abuse? Not really. Although the drugs used for the treatment of ADD and as study aids are technically amphetamines, and have been regulated as highly addictive, empirically they do not have the same addictive potential of those much stronger substances. The first drug that began to be used as a treatment for ADD in the 1950s, which was then known as minimal brain dysfunction, was methylphenidate, marketed as Ritalin. Methylphenidate is a dopamine reuptake inhibitor, and dopamine is a signal to the brain to pay attention.

One way to understand the ADD brain is that it is dopamine deficient, and the ADD child or adult is constantly looking for something to keep themselves awake. By boosting dopamine they are able to better attend to controlling their own behavior, and to the tasks at hand. Methylphenidate also boosts a form of dopamine that enables learning, encourages brain maturation and the differentiation of neural stem cells, and enhances synaptic plasticity. It also boosts norepinephrine levels which helps to focus attention, while suppressing nerve transmissions in the sensory pathways, so that it is easier to block out extraneous stimuli. So while ADD brains are constantly whirring and distracted with the drug they suddenly have clarity and focus.

Dopamine bursts are however the key to all addictive behavior, so the critical distinction between a stimulant with a high addiction profile and those with lower addiction profiles like methylphenidate and its later cousin Adderall is the degree of dopamine burst it creates, and the way and quantity by which it is ingested. Methylphenidate and Adderall – a mixture of amphetamine analogs - although they can suppress appetite and have some of the other physiological effects of amphetamines, do not appear to boost dopamine in the same dramatic fashion as cocaine or methamphetamine, at least for the vast majority of children and adults who are prescribed them.

This is not to minimize to fact that there are people who have taken the drugs for recreational purposes, and in higher than recommended doses, and developed dependence on them with health and psychiatric consequences – you can find these anecdotal cautionary tales easily by googling "adderall." But the tens of millions of children and adults who have taken them – with and without prescriptions - without developing dependency argues that they are safer than the moral panic about them would have it. Studies have shown that while ADD adults are more prone to substance abuse, which for some may be a dysfunctional form of self-medication, that children and adults treated with stimulant drugs are less likely to abuse drugs.

Although much of the following argument applies to methylphenidate and Adderall, I also want to mention the newer drug modafanil sold as Provigil. Modafanil was originally developed as a treatment for narcolepsy, but is now prescribed for night-shift workers. It has been shown to be an effective treatment for some adults with ADD, and is displacing the use of amphetamines by the military. Modafanil has far fewer side effects than methylphenidate or Adderall, and an even lower addiction profile, but has many of the same benefits, such as reducing fatigue, and improving focus and working memory. Insofar as the argument against the use of methylphenidate and Adderall turns on concerns about their side effects and addiction risks then I would point out that my argument could then simply be applied to newer, safer methods of cognitive enhancement such modafinil.

Because of the history of amphetamine abuse and their risks, however, methylphenidate and Adderall are unfortunately classified as Schedule II drugs, the most restrictive category. It is of course a legitimate concern that the sale and taking of these drugs without a prescription therefore involves felonies. But I do not believe that our drug laws are terribly rational. Alcohol and tobacco cause the most death and disease in society, while are both legal. Cannabis, while causing little death and disease, is still illegal in most places and half a million Americans are in the criminal justice system as a consequence. Tylenol is a leading cause of liver disease and accidental poisoning death in the US but is sold over the counter, while a prescription for methylphenidate has to be renewed monthly with a physical prescription taken to the pharmacy. Suffice it to say that taking some Adderall or Concerta on Sunday night to study or write a paper is far less dangerous than the substances and activities that university students are often doing on Friday and Saturday night, and that our drug laws should be reformed.

There is also a pernicious class-biased effect of the criminalization of methylphenidate and Adderall, similar to the effect of allowing middle-class people to get prescriptions for medical marijuana while poor pot smokers go to jail. Because of the flexible nature of the ADD diagnosis, the greater academic pressures on affluent youth, and their greater access to health insurance and child psychiatry, the heavy regulations on the prescription of stimulant drugs effectively institutionalize cognitive advantages for the affluent, and cognitive disadvantage for undertreated non-affluent.

(Part Two)

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James Hughes Ph.D., the Executive Director of the Institute for Ethics and Emerging Technologies, is a bioethicist and sociologist who serves as the Associate Provost for Institutional Research, Assessment and Planning for the University of Massachusetts Boston. He is author of Citizen Cyborg and is working on a second book tentatively titled Cyborg Buddha. From 1999-2011 he produced the syndicated weekly radio program, Changesurfer Radio. (Subscribe to the J. Hughes RSS feed)



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