In my previous post, I presented and refuted some of the objections to the economic disincentives model (EDM). Namely, not everyone agreed with my conclusions. 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 – recall that previously I concluded that all forms of Amphetamine (including Adderall) need to be prohibited, However, others took issue with the conclusion that the economic disincentives model (EDM) could be an option for public policy on extended release forms of Methylphenidate.
In this post, since it makes sense to group similar objections together, I'll explore and answer several objections from neuroethicists that think EDM is too permissive: Hall et al., Faulmüller et al., and Van der Eijk.
Wayne Hall, Brad Partridge, and Jayne Lucke claim that my proposal sounds plausible but that there is a number of major problems with it. They insist that it should not be assumed that sustained release forms of drugs will be safer than immediate release forms when these drugs are widely used in the community. They also have doubts about the feasibility and effectiveness of EDM. Namely, they think that tight regulations, licensing and high taxes would be major disincentives for both the pharmaceutical industry and would-be stimulant users, so EDM may actually boost grey- or black-market for stimulants.
Other objections of Hall et al.
Hall et al. also contend that EDM would require a modification of the 1971 UN Convention on Psychotropic drugs. Furthermore, they think that the bioethical debate about enhancement use of stimulants might have disastrous consequences. Namely, proposals for liberalization of enhancement use of stimulants might actually lead to severe restrictions if not prohibition even of medical use of these substances, because society might recognize such use as an increasing social problem. This would make the population that really needs these medications as treatment for ADHD and other conditions vulnerable.
Reply to Hall et al.
I agree with Hall et al. that it should not be taken for granted that sustained release forms of drugs will be safer than immediate release forms. Indeed, in my proposal I have insisted that the danger profile of methylphenidate would have to be carefully analyzed and empirical studies confirmed by independent researchers before any change in current prohibitive policy is allowed. As for the worry that EDM may actually boost grey- or black-market for stimulants, it is safe to assume that it will not boost it any more than prohibitive policies do. On the contrary, if there are legal means of marketing or obtaining a commodity, the majority will prefer to act within the bounds of the law.
On repercussions of advocating liberal policies
Regarding the conclusion that EDM, or any other liberal policy, would require a modification of the 1971 UN Convention, their argument is not convincing. Article 3 of that convention states that a preparation may be exempted from the current regulatory regime if it is compounded in such a way that it presents no, or a negligible, risk of abuse and the substance cannot be recovered by readily applicable means. As I noted above, whether this is the case with extended release forms of methylphenidate is an empirical question which can be settled with sufficient research.
Finally, adverse reactions by conservative factions are hardly reason enough to censor the bioethical discussion. Indeed, different policies are (and should be) judged by their merits – including the ability to provide reliable information on the prevalence of use. Therefore, even if there was a rash prohibitive response to liberal policies on stimulants that would restrict medical use, such responses would be short-lived, as they benefit no one and harm the interests of many citizens.
But others have different objections: cognitive enhancement can cause more harms then just physiological dangers.
Nadira Faulmüller, Hannah Maslen and Filippo Santoni de Sio argue that new cognitive enhancers are psychologically different from other, well-known drugs such as caffeine, because they are perceived negatively by the public. They point out that psychological valence accounts for much. Namely, some of the “old” substances like alcohol might be objectively more dangerous than methylphenidate. However, they are loosely regulated because they are perceived more favorably, and even as socially desirable. Moreover, new enhancers are not only judged negatively, but their efficacy is strongly exaggerated by lay people. Independently of any direct negative physiological effects, enhancers might generate some indirect psychological costs, such as: attribution of performance (any success users might achieve would be attributed to the enhancer), dehumanization (users might be perceived as being more similar to automatons), and ostracism (enhancement users may be shunned by others).
Reply to Faulmüller et al.
I agree with Faulmüller et al. that views of the lay public need to be taken into account. However, these views can also be changed as a result of sufficient information. Consider yet again the example of tobacco: smokers used to be considered socially more apt and/or desirable, but thanks to the information on objective harms of tobacco, nowadays smoking is more likely to be seen as a sign of weakness or poor taste. Indeed, smokers are increasingly ostracized, and that is precisely the point of any „discourage use“ policy, including EDM. As for dehumanization and misattribution of performance, even though some people might have such exaggerated reactions to the use of enhancers, these concerns are generally matters relevant for individual choice, but not relevant for public policy. Public policy in democratic societies usually protects autonomous choice of individuals, as long as this does not harm others.
However, some are convinced that my analogy with tobacco is precisely the reason to support a more prohibitive response.
Yvette van der Eijk claims that arguing for EDM based on an analogy with tobacco might not be persuasive, since tobacco control policy is taking a turn toward prohibition. She explains the idea of a “tobacco endgame”, the complete phasing out of tobacco consumption by prohibiting sale to newer generations even when they reach the age of adulthood. Apparently, this idea has become popular in the tobacco control literature in recent years, and is already being considered in several countries. She defends such prohibitive responses by pointing out the addictive properties of nicotine, and further distinguishing between recreational and „addiction maintenance“ use. The addictive properties of nicotine guarantee a high proportion of „maintenance smokers“, which in turn means that discouragement policies are unlikely to have much effect. Hence the only really feasible solution would be to prevent people from becoming addicted in the first place by prohibiting the substance for the newer generation and „phasing out“ the „old“ users.
Reply to Van der Eijk
I agree with Van der Eijk that smoking is a nasty habit that causes considerable amount of harm and often leads to dependance. Indeed, most long-term smokers need substantial interference by outside factors in order to get rid of the habit, and even if they are successful there is the danger of relapse. However, we should keep in mind that protecting autonomy and life-plans of some should not be done by severely restricting autonomy and life-plans of all. A harm that is restricted to self should not be made illegal lightly - that would mean that for example a “tattoo free” generation might be the next move of some conservative factions.
More is needed to justify prohibition
Van der Eijk's argument on „addiction maintenance“ has more merit. However, not every dependance is the same. In another article I provide a longer argument, but in this context I think it suffices to note that dependance on nicotine does not entirely disrupt all other rational life-plans a person might have, whereas addiction to say heroin does. For instance, while smoking a person can also be meaningfully socially connected in various capacities. Opposed to that, full-blown heroin addicts will often engage in risky, degrading and illegal activities, which is not acceptable as a rational life plan under fair terms of social cooperation. If smokers want to keep their habit in the privacy of their homes, society is hard pressed to find faults in their right to do so.
The question of arbitrary discrimination of younger adults is an additional reason to believe that „end games“ or any other prohibitive policy on tobacco would be a failed and illegitimate social policy. Indeed, even though the idea is being considered in several countries, such a response would be short-lived, at least in liberal-democratic countries.
Having answered the questions and issues raised by the authors who think EDM is too permissive, it is time to respond to additional points of view. Namely, some think that the shortcomings of EDM are not that it is too permissive, or too conservative, but that it ultimately fails to protect the values of democratic society it purports to defend. To what do they object? And how do I respond? Stay tuned to find out...