In my previous post, I analyzed the dangers of using Adderall and Ritalin for cognitive enhancement (CE). I concluded that anything beyond the prescribed therapeutic use of any form of Amphetamine, including Adderall, needs to be prohibited, while the economic disincentives model (EDM) could be an option for public policy on extended release forms of Methylphenidate (like Ritalin-SR). However, not everyone agreed with my conclusions. There has been a considerable amount of constructive criticism regarding my proposal, written by some influential neuroethicists. In this post, I'll explore and answer several objections.
Even though Sandberg does not entirely disagree with my analysis, he insists that there could exist other enhancers besides psychostimulants that might have very different usage and risk profiles and that are likely to lack autonomy-impairing addiction properties. According to him, they are likely even safer than the extended release methylphenidate and are not legislated by any UN Convention. As such, they should hence be regulated even more permissively. He contends that the greatest problem for regulation is insufficient information, and that the method used to regulate enhancers will affect what information will become available for fine-tuning policy.
Sandberg's other objections
Even though we both agree on the point that bans and laissez-faire approaches do not provide the necessary information, Sandberg argues that adding taxes and fees as suggested in EDM does not give much feedback except usage statistics. Even though he acknowledges that having licensed users undergo regular medical tests (as envisioned by EDM) would provide more relevant information, he considers that EDM would risk creating principal-agent problems between the interests of users, companies, testing bodies and society in general. Society would benefit from extensive and careful testing, while users would not be interested in paying too much money and privacy for it. He concludes that the way to minimize harm would be to accumulate relevant information as early and accurately as possible, which entails a liberal permissible regulation of safer enhancers.
Reply to Sandberg
I heartily agree with Sandberg that regulatory models which could provide the missing information would be more effective, even if their preliminary assumptions turn out to be incorrect in the long run. I also agree that there might be more CE drugs to which a moderately liberal regulatory approach could be applied (e.g. Modafinil). However, Sandberg failed to provide a realistic alternative model, so, apart from extending EDM, there is no feasible alternative option from which to choose. Even though EDM might need lots of fine tuning, that can only be done once it (or a similar model) is implemented and the information on the health costs associated with CE drug use becomes known.
His other concern is with the acceptability of the licensing procedure and other measures in EDM. However, similar requirements are accepted worldwide in the case of vehicles: in order to use them, a person must pay fees for a training course and pass an exam as proof of competence. Then, when the vehicle is bought, taxes should be paid. In order to use the vehicle, an appropriate insurance must be taken and both the vehicle and the driver should be registered by a government agency. Finally, while using the vehicle, taxes on fuel, tolls and appropriate fees for regular technical check-ups must be paid. Since all these measures are readily accepted, there is no reason to doubt the acceptability of similar measures in EDM.
But others have different objections: CE can be achieved in more ways than one. Instead of medical drugs, people might be using trace elements, vaccines or medical devices.
Neil Levy agreed that EDM may be appropriate for regulating extended release forms of Methylphenidate and that Amphetamines need to be prohibited. After this endorsement, he took issue with my ruling out of mandatory use for other forms of CE. He argued that in other instances, the costs can be low enough, and the benefits great enough, to make it appropriate to require enhancement. He gives the examples of vaccination and fluoride in the water supply, which allegedly override any informed choice regarding use.
Reply to Levy
As for Levy's comments about the applicability of mandatory cognitive enhancement use and his example of fluoride, there is a huge difference in providing trace elements that might increase the health of the population and providing mind-altering drugs. That being said, the use of fluoride in his example is actually not mandatory. Many people purchase bottled water or use carbon filtering, and the coercive power of the state is not brought to bear on them to change these practices. Mandatory use is indeed very hard to justify. Even vaccination is mandatory mostly for minors – in this case the state could sometimes override the wishes of the parents because the life and interests of a person not yet capable to make autonomous choices is at stake, and the parent's choice could be dictated by religious or other reasons that the minor might not endorse. However, in the case of adults, barring a major health disaster (e.g., plague outbreak), coercion backed by the immense power of the state needs to be limited, even if society and individuals might perhaps benefit by state intrusion.
To give one example, governments that have historically made mind-altering drugs mandatory (e.g., Togo militarists in Japan during the 2nd world war) have found it easy to make such legal requirements. Making something mandatory is easy – a law that suits the purposes of the elite is just enforced and backed by sanctions. However, such a law would not be legitimate or democratic. Levy is right in that I have dismissed mandatory use without too much space allocated to discussing the issue. However, I have relied on democratic values and the overwhelming demand to respect the autonomy of citizens as being tacitly assumed.
However, some are unconvinced that my conclusions regarding autonomy are sound, and presume that a liberal-consequentialist perspective would render any prohibitive response illegitimate.
Savulescu contends that my proposal is too conservative and too prohibitive when viewed from a liberal consequentialist perspective. He relies on the argument from Mill's On Liberty to show that any intrusion of the state is illiberal and undemocratic.
He takes issue with my claim that the use of amphetamines (like Adderall) would lead to the undermining of autonomy and addiction, and argues that addiction is primarily imprudent pleasure seeking and that addicts are not incompetent and need not be harming anyone else. Consequently, they should be free to harm themselves, and the state should not interfere with their freedom.
Reply to Savulescu
First of all, Savulescu's claim that my proposal is too conservative is problematic. Since “conservative” is defined as “Holding to traditional attitudes and values and cautious about change or innovation” and the EDM proposes a drastic change in regulation of methylphenidate, my proposal is everything but conservative. He might be opposed to prohibition of amphetamines, but since Amphetamine can cause aggression, impulsivity, manic behavior and psychotic episodes, and so can cause considerable danger to users and others, a form of prohibition might be legitimate even based on a liberal-consequentialist reading. However, if an individual, for whatever reason, voluntarily and autonomously chooses to consume illicit drugs with full knowledge of their addictive properties and harmful physiological and social consequences, the society would be legitimate in punishing the producers and distributors of illicit drugs, while drug addicts might need to be treated and not punished. To conclude, an argument based on autonomy does exclude certain types of prohibition (prohibition of possession and use) but not others (prohibition of production and sale).
Having answered the questions and issues raised by the Oxford group, it is time to respond to other points of view. Namely, not everyone thinks that my proposal is too conservative. Quite to the contrary, some think it is too permissive. To what do they object? And how do I respond? Stay tuned to find out...