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), 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), and there are those that think my argument in general and EDM in particular are failing to address the relevant issues in regulation of CE. In three separate posts I have responded to these objections.
In this post I'll explore and respond to several suggestions from neuroethicists who focus less on shortcomings, and more on suggestions on how the argument and model of public policy might be improved: Hank Greely and Forlini et al.
Hank Greely starts by praising the analysis of the safety and efficacy of Ritalin and Adderall. He finds particularly important the analysis of the differences between the extended release and the instant release forms of medications. He notes the necessity to go beyond summarizing the existing research to pointing out what further research would be useful. He points out that we know very little about the effects of long-term use, either regular or sporadic, of these drugs on healthy adults. He also notes that it is also necessary to have a discussion of mechanisms to assure that unbiased scientists would produce relevant research on various cognitive-enhancing drugs.
After pointing out strengths of my analysis and potential areas of improvement, he briefly criticizes my dismissal of the proposal for a “Regulatory Authority for Cognitive Enhancement” (RACE).
Even though he agrees with me that creating a new statutory regulatory body like RACE is difficult and expensive, and that it might not conform to the 1971 UN Convention on Psychotropic Substances, he thinks that those flaws might be overcome. His proposal is similar to mine - the use of an existing agency, similar to the Food and Drug Administration (FDA) in the United States. He contends that FDA might be better placed not only to make comparisons between safety aspects of different drugs, but also to forecast problems for which intermediate regulatory models would respond, and examine, carefully, the match between those problems and available solutions. Greely points out that the focus of my analysis was on legitimate or appropriate policies, not about feasible politics.
He concludes that more needs to be said about foreseeable ways in non-ideal conditions of politics may affect even ideal recommendations. He does note the constraints of space and my limited case analysis is a good start for further discussion, by experts, governments, and the public.
Reply to Greely
First of all, I would like to thank Prof. Greely for his kind words and constructive suggestions. Indeed, he is right that more needs to be said on a range of topics, from feasible politics via other possible models to discussing further avenues of unbiased research on CE drugs. He has also very graciously provided explanations why these shortcomings are to be expected in any analysis, and basically offered more words of praise for my whole research project. However, I do feel the need to clarify one issue. Even though he believes that RACE could be amended to outmatch EDM as a regulatory solution, the argument has not been provided yet. Furthermore, the precise reasons why EDM is more preferable to RACE go beyond a limited case analysis of two stimulant drugs and delve deep into the values of a democratic society. For example, the questions of justice and accumulation of power cast serious doubts on RACE. The provisions of EDM, on the other hand, are precisely motivated by these “ideal” concerns of respect for individual decision-making and benefiting the least advantaged, as opposed to merely efficiently regulating the market.
The question of more substantive values beyond safety and efficacy is precisely the point which is raised by other neuroethicists with constructive suggestions.
Cynthia Forlini, Eric Racine, Jochen Vollmann and Jan Schildmann agree with my case-by-case approach, but they argue that public policies on CE should not only be based on an assessment of benefits and harms of the substances but also be informed by evidence on the perceptions and views of the groups that are affected by CE (i.e., stakeholders). They point out that assessment of evidence may be influenced by the experts’ personal perceptions, experiences, and values and that the assessment of benefits and harms may well differ depending on whether a person is directly affected by a policy recommendation or not. They emphasize the fact that the involvement of stakeholders affected by policies has been incorporated as a requirement for the assessment of the quality of clinical guidelines. They add that empirical research indicates that stakeholder views on the appropriateness of a policy rest on more fundamental values that could be promoted or jeopardized by a liberal policy.
Objections by Forlini et al.
Forlini et al. also point out that their research showed that effort put into an academic performance, which is linked to the authenticity of persons, is an important value to consider for stakeholders. The further point of criticism Forlini et al. Raise is that my argument did not distinguish between requirements of moral acceptability (e.g. efficacy, safety and respect for autonomy) from the requirements of moral praiseworthiness (e.g., self-realization, moral growth, justice). They conclude that research on stakeholder perspectives shows that the criterion of moral praiseworthiness captures concerns about the impact of cognitive enhancement on values beyond safety and efficacy.
Reply to Forlini et al.
I would like to thank Forlini et al. for pointing out aspects that need to be included to increase democratic legitimacy of any proposal regarding regulation of CE. Indeed, the analysis of social harms of stimulants should include the points of view of general practitioners who prescribe stimulants and those who use stimulants, whether to deal with a medical condition or as a study aid. Not only would that provide valuable information, but it would also further promote values of the democratic society. As I have noted above, I also agree with the need to go beyond safety, efficacy and autonomy – the questions of justice and not jeopardizing self-realization (e.g. the right to an open future) are indeed important. However, I strongly disagree with their conclusion regarding authenticity and moral growth as criteria for public policy. Namely, as I argued in my first post and article, these could be included at the level of personal or even institutional (e.g., University) choice, but not at the level of society.
A general thank you
Having responded to all comments on my article, I would like to thank everyone who engaged with my research, whether they are neuroethicists who commented on my published work or readers of this blog who were interested in the arguments. A special thank you to Prof. Adam Kolber for inviting me to be a guest blogger at the Neuroethics and Law Blog.
If you are interested in more of my neuroethics research and arguments, you can check out my recent article in American Journal of Bioethics – Neuroscience. Other than that, I can only say, stay tuned. There is more to come on a range of topics: from regulation of CE technology and neuroscientific challenges to ideals of democracy to “neuroscience of ethics” and moral heuristics.