18 June 2009
BMJ 2009;338:b1956
Head to Head
Is it acceptable for people to take methylphenidate to enhance performance? No
Anjan Chatterjee, professor
Department of Neurology and Center for Cognitive Neuroscience, University of Pennsylvania
A drug that can improve your exam results may sound tempting, and John Harris (doi:10.1136/bmj.b1955) believes that we should embrace its possibilities. Anjan Chatterjee, however, argues that the dangers have been underplayed
Why would anyone object to someone choosing to be smarter, better focused, and more productive? Surely cognitive enhancement has much to offer individuals and society, and legal dispensers of methylphenidate (Ritalin) should not object. Unfortunately, the case for healthy people taking this drug is not so straightforward. Doctors routinely decide whether to intervene based on a calculation of relative risks and benefits. Here, the risks outweigh the benefits.
Some doctors might reflexively think that the answer to the target question is an obvious "no." After all, doctors are in the business of treating disease and not enhancing normal abilities. On scrutiny, this distinction proves to be unreliable, particularly when conditions lack clear categorical boundaries. For example, if individuals of short stature can be "treated" with growth hormone,1 does it matter if they are short because of a growth hormone deficiency or because of other reasons?2 Furthermore, the widespread use of cosmetic surgery to enhance normal physical attributes shows that many doctors, given the right incentives and cultural framework,3 become comfortable with non-therapeutic interventions.4
Questionable benefit
The most obvious reason to object to using methylphenidate for healthy enhancements is that the cognitive benefits are minimal5 and the medical risks are not. In the United States, the Food and Drug Administration gave methylphenidate a "black box," the most alarming of possible warnings, because of its high potential for abuse and dependence and its risks of sudden death and serious cardiovascular adverse events.6 Furthermore, the incidence of serious cardiac arrhythmias is likely to be higher in older people with incipient cardiovascular disease, one group that is likely to use the drugs to enhance performance. Non-physicians calling for responsible use of methylphenidate by healthy people7 underappreciate this risk.8
Besides medical side effects, there are also possible cognitive trade-offs. For example, greater focus from long term use of methylphenidate could plausibly produce a loss in creativity, which generally requires a loosening of mental boundaries.9 Such trade-offs are rarely considered or investigated.
In considering benefits, we might postulate that being smart is good for the world. Many smart people would like to believe that products of smartness confer clear benefits to society. Perhaps the brightest getting brighter would produce trickle down enhancements into our communities. But the fact that very smart people generating complicated models to distribute financial risk contributed to the current global economic crisis should at least give us pause. Being smarter does not mean being wiser. Furthermore, this dubious benefit is counterbalanced by two other risks. These are risks of expanding social inequities and inviting coercion.10
Equity and choice
Drug enhancements will be available disproportionately to those with financial means. If enhancements are helpful in getting ahead in a competitive world, then the haves would avail themselves of yet another advantage over the have nots. Clearly, many inequities in education, material goods, and social class, not to mention more fundamental inequities in health care, nutrition, shelter, and safety, already give the socioeconomically lucky disproportionate advantages. However, acknowledging the existence of disturbing inequities does not justify blithely adding more.
Matters of choice can evolve into forces of coercion. Implicit pressures to better one's position in some perceived social order would find a natural conduit in cognitive enhancements. Such pressures increase in "winner take all" environments, in which more people compete for fewer and bigger prizes.11 Professionals in the US work 60, 80, or more than 100 hours a week to the detriment of health and hearth. Children at high end preparatory schools take methylphenidate and its analogues in epidemic proportions.12 This trend is growing among students13 and even among professors.14 To not take advantage of enhancements might mean being left behind. Coercion can also become explicit, as might occur in the military,15 if superior performance by a few is deemed necessary for the greater good. Pilots and police might face similar pressures. Closer to BMJ readers, residents might be forced to take enhancements after being on call to mitigate cognitive deficits brought on by sleep deprivation. Perhaps doctors older than 50 would be required to pharmacologically stave off their fraying cognitive edges.
Endorsing the legal non-therapeutic use of methylphenidate or other cognitive enhancers now is premature. The efficacy and risk of enhancers in healthy people needs to be researched adequately. This information needs to be disseminated broadly. Doctors, educators, and regulators need to articulate professional normative positions on the issue. Enforceable policies to minimise disparities and protect individuals need to be established. Until such preparations are made, it is not acceptable to recommend that healthy people take drugs to enhance performance.
Cite this as: BMJ 2009;338:b1956
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Competing interests: None declared.
References
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