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A recent Commentary in the international science journal NATURE (11 December 2008, vol 456, p.702) discussed the science and ethics of the use of cognitive-enhancing drugs by the healthy. As the article pointed out, substances believed to help people control attention, remain alert when working at night or extra house, and learn faster/better are now in widespread off-label use–used by those who do not have the diagnoses for which these substances were developed.
Coercion–pressure to use these substances even if the individual doesn’t want to–is already being applied (for instance, by the Armed Forces for the use of certain stimulants, and by teachers who believe a child will be less trouble in the classroom if put on Ritalin) and employers began to looking at the possibility of enhancing work performance with drugs some years ago. Since coercion by an employer is one of the plot drivers in The Speed of Dark it seemed like a good topic for this blog.
What is “cognitive enhancement” and what kinds of issues should be considered when anyone (disabled or not) faces a decision about the use of pharmacological or any other method of “enhancement?
The term “cognitive enhancement” is used loosely to cover any of the following: maintaining alertness, including preventing sleep, directing/controlling attention, controlling behavior (when behavior problems are believed to relate to distractibility or obsessive/compulsiveness), increase memory, etc. No one is yet suggesting a “smart pill” to increase IQ twenty points (well–not in this article anyway!) but as more is learned about the biochemistry of sensory processing, memory, learning, and behavior more specific interventions can and will be attempted.
If it were available, there are cognitive enhancements I’d like to have. I have a problem with face recognition, called prosopagnosia…I fail to recognize people I’ve just met (very embarrassing on a boat trip last spring!) and sometimes think strangers are old friends. (I remember clothes and hairstyles–just not faces. So when the person next to me in choir showed up with a new hair-style–I didn’t know who that was until she spoke.) A pill to make my face-recognition module work? Sure.
Maybe.
What’s worrisome is that we do not know what the long-term effects of fiddling with the brain’s biochemistry is, and what little we do know gives cause for concern. The body habituates to external “fixes”–it takes more of the substance to get the same effect, and sometimes new effects (unexpected, undesired) emerge. The plasticity of the brain–it’s ability to adjust to new inputs, to literally grow new connections in response to new conditions–suggests that medication effects could make long-term changes in the brain’s physical and biochemical state.
In addition, the cognitive enhancements in use and in development now are all aimed at things someone else wants us to do–stay awake, work harder, pay attention, sit still, remember more facts longer. Employers want that; teachers want that…but do we want that?
We don’t know that the drug keeping the young doctor “awake and alert” through a 24 hour shift of duty is maintaining the same cognitive competence as a night’s sleep. We don’t know that the child given an anti-depressant because he’s depressed in a bad situation is helped as much as he would if the bad situation were fixed, instead of the child being medicated.
Of course there’s a place for psychoactive drugs–but calling them “cognitive enhancement” seems a stretch. People who do have true clinical depression can benefit from antidepressants; anti-psychotics may help those with psychosis to think more normally. Anti-seizure medications do prevent seizures in some (not all) persons with seizures, and so on. New drugs appear to be able to slow down the progress of Alzheimer’s, allowing the individual to live independently longer.
But so often a drug is the first choice when someone has a problem…and this seems particularly true with children. Rather than looking at the whole situation, and considering if it is a healthy one for any child (and that child in particular), various alphabet soup labels are tossed in the air and out comes the prescription pad. Drugs are used instead of behavioral interventions, instead of a change in setting, instead of approaches that might give the brain time to make its own adjustments.
Then there’s the priority list. Stay awake, pay attention, listen, sit still, work harder, remember these facts…and no mention of those traits and behaviors that would improve the human condition. No mention of enhancing a sense of justice, generosity, kindness, gentleness, the ability to forgive rather than hold grudges.
We don’t need more alert and canny criminals, more terrorists whose improved memories are used to hold old grudges longer, more CEOs whose single-minded attention to the short-term bottom line leads to stupid mistakes and economic trouble for the rest of us. If there were real cognitive enhancing drugs, we might learn to think better–which is more than sitting still in class, learning lists of facts, and looking the teacher in the eye.
Comment by sari — December 22, 2008 @ 6:07 pm
This is a very thorny topic and one destined to generate a lot of discussion.
One can look at psychopharmaceuticals like Ritalin and SSRIs as vehicles to modify the individual’s neurology to some arbitrary set of specifications (e.g., classroom behavior). But consider this: they can, if used judiciously, provide a teaching window, one where the behaviors mastered medicated can bleed over into unmedicated times. It is not about making the individual better or nicer or smarter but about giving them a chance to learn how to self-monitor and gain some measure of self-control, particularly when the behaviors cause the person great misery.
Ritalin, in particular, has been horribly over-used, prescribed by doctors who have no real training in either psychopharmacology, psychology, or neurology. It should never be about being more alert or smarter or acing tests–the people who most benefit simply cannot stop: stop moving, stop thinking, stop doing. They cannot stay focused long enough to complete a task. MRIs and other tests demonstrate differences in activity and brain chemistry, particularly glucose uptake in certain regions of the brain. Unmedicated, many individuals pose a danger to themselves and sometimes to others.
In other words, medication, used properly and for the right reasons, can be a tremendous help. Given the number of bizarre and untested interventions autists undergo at the hands of parents, teachers and medical professionals (using the term here very loosely), medication may be the more preferable route.
Comment by Elizabeth — December 23, 2008 @ 12:50 am
I agree there’s a place for medication, including with some (but I think not all) autists. I’m certainly not arguing for removing all drugs from the possible list of treatments.
What concerned me about the cited article–and the trends in off-label use–is the push to legitimize neuro-active drugs when they *aren’t* necessary and consider them in the same class as improving cognitive function by getting enough sleep or taking exercise (a comparison the article made.)
That, and the assumption (also explicit in the article) that “improving cognitive function” in the very limited sense described would actually solve the problems humanity creates for itself.
This is going to become an ever-hotter issue, not only in disability circles but in the general population–and finding the best balance of use, the most good for the least harm, isn’t going to be easy. I think nearly everyone would agree that someone who’s a danger to himself or others–where a specific drug is known to eliminate or reduce that danger–should have the medication. But to ace the test? You and I say no–but some educators (contributing to this article) and employers say “Why not?”
Comment by sari — December 23, 2008 @ 1:32 am
It might be better (not having read the article) to compare psychoactive medications with the everyday chemicals people use to enhance performance: caffeine to stay alert and focused; alcohol to reduce anxiety and alleviate, at least temporarily, symptoms of depression; nicotine, which seems to effect various parts of the brain in positive as well as negative ways, and chocolate. Human nature being what it is, many people seek ways to enhance their performance which require little effort.
What concerns me is the people who need medication but refuse it on the grounds you cite above. Mental illness effects a disproportionate percentage of the homeless, for instance, yet they cannot be forced to take medication unless they present an obvious public danger. Many, many more people refuse meds but self-medicate with illicit drugs. Others avoid both all medications but behave in ways destructive to both themselves and the people around them.
I don’t believe any magic pill exists that would solve humanity’s problems, but I think it’s also true that definitions of what constitutes normal have changed. The wild and uncontrollable child, once thought to be the product of poor parenting, might now carry–correctly– a label of ADHD or PDD, or both. Too little research has been done on how neurological deficits affect cognition; does medication confer an advantage or simply level the playing field?
Re: autism spectrum disorders and meds. Most autists are comorbid for other neurological disorders. When behavioral interventions don’t work and the behaviors frustrate the individual to the point of regression or withdrawal, meds should be considered.
Comment by Elizabeth — December 23, 2008 @ 9:42 am
The article did in fact compare psychoactive medications to other stimulants/relaxants people use, but in a way that bothered me.
Experience suggests that both undermedication and overmedication by professionals and by untrained individuals create problems. Those who have dealt most with under medication worry about any expressed concern for overmedication, and vice versa.
As I said, finding the right balance is not easy and the topic will remain “hot” in the foreseeable future.
Comment by Timur — January 1, 2009 @ 2:56 pm
I very liked this post. Can I copy it to my blog?
Thank you in advance.
Sincerely, Your Reader.
Comment by Elizabeth — January 1, 2009 @ 3:02 pm
Please do not copy it to your blog. Post the link to it, instead.
As the Policies page explains, these posts are copyrighted.
Thanks.
Comment by Finny — June 24, 2010 @ 1:37 pm
You also have prosopagnosia? So do I (and I am on the autism spectrum, too). Tends to make work difficult, since people change hair and clothes styles so much, and those are what I rely on to recognize folks.