In my previous post, I presented and responded to some more objections to the argument about regulation of cognitive enhancement (CE) and the economic disincentives model (EDM). Namely, there has been a considerable amount of constructive criticism regarding my proposal. Some neuroethicists took issue with my favoring prohibitive policies to dangerous CE drugs such as Amphetamine (e.g. Adderall), while others took issue with the conclusion that EDM could be an option for public policy on extended release forms of Methylphenidate (e.g. Ritalin SR). In two separate posts I have answered these objections.
In this post I'll explore and respond to several objections from neuroethicists who think my argument on policy options in general and EDM in particular are failing to address the relevant issues in regulation of CE: Jamie Nicole LaBuzetta, Brewer & De Grote, and Jessica Flanigan.
Jamie Nicole LaBuzzeta argees that the case for regulation of Ritalin and Adderall is compeling. However, she thinks that it can nevertheless problematic when the same rationale is applied to other drugs with improved risk to benefit ratios. When applied to safer ‘smart drugs’ such as modafinil, an evidence-based regulatory model might actually seem to compel their use. Such a compulsion would be contrary to the very idea of liberty and autonomy, but perhaps there are other ideas and values that should take precedence.
She argues that it is plausible and reasonable to demand from individuals working in high-responsibility roles, such as military, medical, and aeronautical professions to use a safe and effective cognitive enhancing medication, such as modafinil. She considers different principles that could support her conclusion and opts for Utilitarianism.
Reply to LaBuzetta
First of all, I am well aware that, due to reasons of space, my article on Ritalin and Adderall, left out some very important CE drugs, such as Modafinil. However, I believe that EDM can be successfully extended to most new CE drugs that are not too dangerous and/or addictive. The reason for this is that newer CE drugs are likely to have many unknown effects. Even if clinical studies prove they are safe and effective for specific pathologies, the data on effects of prolonged use needs to be somehow generated. EDM, with the requirement of annual medical testing and additional insurance is specifically designed to fill that gap.
Limits of Utilitarianism
Regarding mandatory use by certain professions such as military pilots, LaBuzetta is right to note that these are issues that EDM did not tackle. Indeed, military pilots are frequently ordered to take even dangerous amphetamines on prolonged combat missions. However, I think that her choice for Utilitarianism as the right ethical framework for regulating these specific cases is problematic, because it demands too much information and cognitive resources for decision making which is not available and thus is not feasible.
Foreseeable consequences are not enough
Utilitarianism requires that all alternative responses are considered, to calculate all consequences of all identified options, to predict and develop contingency plans for all unintended consequences, and to calculate the probability that a certain response sets a precedent for other circumstances where the information may be less reliable. All this creates a nice optimization model, but no mind or machine can solve moral problems in this way. In the real world, even with “safer” smart drugs we just don't know enough to rely on foreseeable consequences alone. That is why in any discussion on regulatory options, in addition to consequences, we need to take rights and virtues seriously.
However, others have different objections: even if we opt for deontological principles, such as justice, EDM may fail to promote it.
Cameron Brewer and Heather De Grote argue that if principles of bio-medical ethics are considered more thoroughly (specifically, the principles of justice and non-maleficence), EDM must be rejected. They claim that EDM is at odds with the “fair opportunity” rule: it would deny the social benefits of enhancement on the basis of undeserved disadvantageous properties. They grant that some form of “discourage use” model might be applicable, but that it should not be as costly to the consumer as EDM.
Brewer's and De Grote's other objections
According to Brewer and De Grote, EDM would almost certainly create an even greater gap between the haves and have-nots. It would effectively deny the social benefits of extended release formulas of methylphenidate to the economically disadvantaged. Furthermore, they argue that EDM would harm the interests of the disadvantaged, as it would exacerbate the already increasing academic achievement gap between the rich and the poor. EDM would ensure that only those with higher incomes would be able to buy and use methylphenidate, while the poor would have to keep their uphill struggle for academic achievement without it.
Reply to Brewer and De Grote
Since EDM has been developed precisely as a means to protect the rights and interests of the disadvantaged, this is a serious objection. However, Brewer's and De Grote's argument would only be convincing if EDM would make CE drugs so expensive as to be unaffordable for the poor. Consider once more the analogy with tobacco: discourage use policies on tobacco introduces taxes, which are sometimes very high. In Norway, they amount to 200%. And yet, even though cigarettes are not cheap, most smokers in Norway live in poorer regions and earn low incomes. Now, it is obvious that extra taxation did not make tobacco unaffordable to the poor. Indeed, EDM envisions that the prices of CE drugs would be regulated: they would contain the standard costs of production and distribution, the profit margin would be limited and an additional tax would be imposed. This means that regulation could be fine-tuned if it turns out that the poor are disadvantaged in academic achievement due to the price of CE drugs.
Do CE drugs offer advantages or disadvantages?
An additional problem for Brewer's and De Grote's objection is that they seem to assume that CE drugs would offer only a competitive advantage, and no health disadvantages. This is problematic in several respects. Even though nicotine can also be seen as a mild cognitive enhancer, it offers mostly health disadvantages. Given that stimulants are known to cause nervousness, drowsiness, insomnia, adverse effects during pregnancy, and even serious cardiovascular adverse events, ignoring these effects as potential disadvantages seriously undermines the argument. Indeed, EDM's requirements of training and licensing for CE users actually protect the interests and rights of the disadvantaged, who are frequently targeted by promotional practices of industry which promise social and other advantages by use of their product. That is why I find the argument that EDM would be rejected based on the principle of fair opportunity unconvincing.
But, maybe autonomy should take precedence over justice, and perhaps my argument for different regulatory responses fails to respect autonomy sufficiently.
Jessica Flanigan argues that even amphetamine and instant release forms of methylphenidate should be legally available because 1) prohibitions of recreational drugs are disrespectful to users 2) even addicts are sufficiently autonomous with respect to their choice to use drugs and 3) regulators are not in the best epistemic position to judge whether the risks of amphetamine and instant release forms of methylphenidate warrant prohibition. She insists that even though some drugs reliably undermine users’ life-plans and autonomous capacities, policymakers should nevertheless permit drug use because the appropriate response to the value of autonomy is respect, not to promote autonomy.
Flanigan's other objections
Flanigan also thinks that my argument rests on a dubious characterization of the psychology of addiction, as some empirical evidence suggests that addicts are autonomous when they choose to use drugs. Finally, she claims that it is illiberal to permit or prohibit drugs based on a judgment about whether the potential benefits to the user justify the risks users face. Her view is that consumers have the authority to decide for themselves whether it is worth it to risk their health for the sake of pharmacological benefits, either for enhancement or recreation.
Reply to Flanigan
Even though I agree with Flanigan that autonomy is very important, and that the state needs to respect it, I disagree with her view on what such respect entails. Consider the following analogy: many individuals might find explosives and rocket-launchers helpful or fascinating for their rational life-plans, and these could be used responsibly (e.g. as a part of weapons collection or for leveling the ground). However, the threat of irresponsible use of such objects is such a danger to others that the state is justified in prohibiting possession of rocket launchers and explosives by members of the general public. As it is reasonable to endorse a system in which people are not allowed to walk around with explosives and rocket-launchers, it is perfectly rational and in accordance to autonomy to limit availability of amphetamines.
Respect for autonomy suitably defined
Namely, a substance for which there is overwhelming empirical proof that it can impair cognitive and volitional capacities (the presuppositions of autonomy), and cause aggression, erratic and violent behavior, is not (and should not be) subject only to the authority of the consumer. However, in my article I do note the need to respect even some of the more self-destructive wishes of competent adults. Indeed, I have concluded that when a person does voluntarily and autonomously choose to consume amphetamines with full knowledge of their addictive properties and harmful physiological and social consequences, the society would only be legitimate in punishing the producers and distributors of these drugs, but not the users.
Having answered the questions and issues raised by the authors who find faults with my argument and EDM, it is time to respond to additional points of view. Namely, instead of focusing on shortcomings, some neuroethicists have offered constructive suggestions on how the argument and model might be improved. So what do they suggest? And how do I respond? Stay tuned to find out...