Abstract

Introduction

Biomedical and technological developments, regarded as having the capacity to improve the body's appearance or function, are often termed ‘enhancements’.1–3ⁱ Over the last 15 years or more, bioethical and policy discourses have questioned the appropriateness of enhancements for individuals and societies.4 5 Discussions have turned on the problems of differentiating enhancement from therapy, the hubris of changing nature and the potential for exacerbating social inequalities. Such questioning has resulted in sometimes acrimonious debate playing out in journals, conferences and in the meeting rooms of learned societies and policy advisory committees—as well as in more public arenas. These widely circulating questions and concerns around enhancement are, no doubt, important matters for consideration, but we believe they are not the only issues of import. More needs to be understood about the social, political and historical contexts in which ‘enhancements’ arise, as well as the reception and uptake of specific drugs or devices.6–8 Further, the potential of new technologies to reconfigure health, medicine, social relations and subjectivities is also relevant to bioethical debate. Yet, if and when this complex issue appears within bioethics discourse, it is often theorised in isolation from other traditions that have taken the relationships between materials, bodies and societies to be key foci.

In this article, we suggest that the empirical medical humanities and social sciences can contribute meaningfully to societal discourse around enhancement in two key ways. First, and most importantly, by attending to issues less commonly considered in current debates. Second, by providing methodologically robust studies of actual practices involving technologies and chemicals regarded as enhancing (which might intersect directly with—and in some cases challenge—bioethical deliberation).9 We take these matters in turn, with the first and substantive focus of this paper examining how research foci within the medical humanities and social sciences might (re)direct analytical attention to the tools, bodies and institutions that populate debates around enhancement. Then, we move to a more specific account of ‘cognitive enhancement’ using pharmaceuticals meant for attention disorders. These are employed as a case study of empirical engagement with a matter of bioethical concern, in order to consider the benefits to bioethics that such analyses might afford. Debates around drugs taken to have enhancing properties to the human brain are wide-ranging; such pharmaceuticals attract broad attention due to the wider social and legal contexts of their use and the potential implications for personal responsibility and liability that come with this. An exploration of extant studies is indicative of new empirical research trajectories that might be considered, and the salience of such scholarship for bioethical deliberation.

Exploring new terrain

We outline some research questions and directions that might contribute to research on enhancement that intersects with existing bioethics scholarship. As a consequence of our own inclination towards the field of science and technology studies (STS), we start with specifying questions that direct the gaze of scholars to the objects around which bioethical debate circulates (eg, pharmaceuticals), before considering the sociotechnical networks that enable, legitimise and sustain their production and consumption.

Like others, we feel that the substantial body of interdisciplinary STS scholarship on the social shaping of technology is of immediate relevance and import to our considerations.2 6 8 10 Such work seeks to open up the ‘black box’ of technology and consider the ways in which a range of social and economic factors construct the eventual form and feel of an object. In the case of enhancement, we might ask: what ideas about society, of the body, and of individual hopes and fears are imagined and/or channelled within processes of innovation? What values—clinical, scientific, economic, societal and so on—are ‘inscribed’ in particular substances and technologies deemed to be enhancing?11 How are the practices of potential users configured in the process?12 Scrutiny of the circulation and transformation of different kinds of value and values within the innovation processes producing technological enhancements will likely represent an interesting case for scholars who have attended to these issues in more straightforwardly biomedical contexts (such as in drug trials, trial recruitment and marketing).13 Disaggregating the different values and practices of valuation constitutive of the innovation and consumption of materials purchased (in formal, grey or black markets) for their enhancing properties also serves to trouble the more essentialist claims of some bioethical commentators who present these as unproblematic social and individual goods.3 6 8 10 14

Empirical analyses of pharmaceutical cognitive enhancement

Throughout our analysis, we have sought to take care over how we use the term ‘enhancement’, indicating what empirical research agendas might be propelled through an acknowledgement that there are a number of individuals and groups who actively use this word and ascribe it to actual or imagined objects around which social practices are orientated—as well as many more people who (seek to) ‘enhance’ their bodies and brains in the absence of this idiom. In addition to being of import for the wider medical humanities and social sciences, we believe (and in so doing take cues from scholars such as Adam Hedgecoe) that empirical attention to the discourses and objects associated with enhancement might also better ground bioethical claims and appraisals in this area.9 Given that qualitative and quantitative methods have become more common in bioethics, we suggest that these methods can help to illuminate how ethically significant issues related to enhancement play out in everyday life.53 Practices of enhancing cognition, for example, have been central to much of the bioethical discussion that focuses explicitly on enhancement, especially the use of pharmaceuticals that promote concentration and alertness (for instance, brand names Adderall and Ritalin). Bioethicists of a more libertarian bent argue that such drugs should be more widely and freely available to those who want them, and that potentially citizens have a duty to consume them.14 Arguments like these can be seen as situated within a broader discourse of what social scientists have referred to as ‘biological citizenship’—the implicit or explicit connection of citizenship to somatic states or processes.54

Work is being produced that is seeking to quantify the degree to which drugs like Adderall are being used (eg, by university students).55–57 Interview studies are concerning themselves with the texture of this use and the meanings that are ascribed to it.26 58–61 Notably, for instance, a recent paper by Singh et al57 underscored that many UK students were not familiar with cognitive enhancement. Such scholarship is needed in order to ensure that bioethical analysis is grounded in what seems to actually be happening in schools, workplaces and in the home—and what feasibly, based on empirical research on current practice, could start to happen.7 This is in contrast to a common bioethical focus on more speculative matters, and by commentators who may be geographically, professionally and personally distant from the figures that populate their imaginaries.

One useful resource is Catherine Coveney's sociological study of a range of individuals (including university students, health professionals and other shift workers) asked to envision the use of a drug promoting wakefulness (specifically, modafinil; brand name: Provigil).6 7 Her findings showed that potential uses of this enhancement included ensuring safety at work (eg, ameliorating the dangers posed by sleepy surgeons), but also as a study aid. However, perceptions both of legitimate use and the legitimacy of the drug per se were tightly interwoven with its legality, and how readily available it was (eg, from local pharmacists, without a prescription, or from physicians only).62 Accordingly, what Coveney's research shows is that public attitudes towards enhancement drugs are linked to broader feelings towards pharmaceuticals more generally—and, specifically, the ways in which (to borrow historian Keith Wailoo's term) the ‘identities’ of drugs are constituted through regulatory regimes.63 64 This insight has salience for bioethical debate that might take the meanings of pharmaceuticals to be solely a function of personal mores, as opposed to being powerfully shaped by the social frameworks in which they and their consumers are embedded.65–67

Other work by social psychologist Ilina Singh directs attention to the actual users of pharmaceuticals. One major theme around cognitive enhancement is ‘authenticity’, and bioethical scholarship focusing on this has until recently operated rather tangentially from empirical research. Questions discussed within the bioethics literature include what it might mean to live authentically, whether regular pharmaceutical use necessarily results in an ‘inauthentic’ life and if medication can in itself enhance authenticity. Conclusions may seek to direct the use of enhancements, including both restrictions and expansions of access to these drugs and technologies.68 A major contribution from Singh is her qualitative work with children diagnosed with ADHD, in which discussions took place around the relationship between psychopharmaceutical consumption and understandings of authenticity.69 70 For this work, Singh interviewed more than 150 children between 9 and 15 in both the USA and UK. As she shows, drugs are not viewed as necessarily challenging or compromising characteristics associated in the bioethics literature with authenticity, and in some cases are figured by children as supporting, for instance, moral agency.70 This is suggestive of the degree to which the use of psychopharmaceuticals that act on cognition by consumers who do not have a psychiatric diagnosis may also refrain from seeing the use of Adderall or Ritalin as compromising their autonomy. There are implications here for bioethical debates around whether individuals should imbibe these substances in order to preserve their authenticity. Empirical work on authenticity potentially is of interest to philosophers concerned more directly with this concept per se.

Perspectives from users of ‘enhancements’ have also been the focus of sociologist Scott Vrecko's research.26 61 His participants were university students at a US institution who used Adderall and Ritalin as study aids. Vrecko asked young men and women about their experiences of consuming such drugs, and elicited striking narratives of their practices. In particular, he revealed the diverse kinds of illicit exchanges through which prescription drugs come to be used for non-prescribed purposes, as well as the highly emotional impact of drug effects, whereby his respondents detailed how it felt to be ‘on’ psychopharmaceuticals that were understood by them to improve their work. Students discussed feelings of channelled interest and enjoyment (ie, a tight focus on, and pleasure in, the studies they were immediately employed in and not other things happening around them), ‘drivenness’, and feeling mentally and/or physically ‘up’.61 Such findings resonate with the more recent research of Margit Anne Petersen and colleagues, who likewise have underscored the role of prescription stimulants in sharpening students’ focus on their work, as well as on the subjective experience of work per se (and also on the moral ambivalences that characterise drug use in this context).59 60 These experiences challenge the more ‘unemotional’ (as Vrecko puts it), sometimes strongly rationalist, accounts of decision-making and use that have found a home within much bioethical deliberation on cognitive enhancement. Hence, Vrecko's and Petersen et al's findings are suggestive of the need to bring in the perspectives of actual users into the discursive spheres of bioethical and policy deliberation.

Work such as that summarised above thus complicates bioethical claims-making by underscoring the ways in which multiple meanings adhere to substances. As Coveney, Singh, Vrecko, Petersen and others remind us, drugs are never just their chemical constituents. Rather, they may take on a variety of ‘identities’ (and have different effects) depending on the context within which they are (or realistically might be) used. Many standard analyses of risk and benefits of pharmaceutical means of enhancing cognition take for granted what a drug ‘really’ is; that is, they are concerned solely with its active ingredients, mode of biological action and physiological effects. In so doing, commentaries and appraisals can elide the diverse and shifting societal understandings of the nature of the substance in question.6 8 Besides holding science and society as separate domains, in these cases recommendations for policy and practice can be problematic as they might lack social salience. If a culturally impoverished understanding of a drug is mobilised in debate, the complexities of deciding whether or not this substance can, should or must be used are obfuscated, and so the legitimacy and utility of any conclusions reached are lessened. Our point is one that will be familiar to scholars concerned with the social lives of pharmaceuticals: that understandings of drugs and their effects are mediated through their use, the context of this, and who drugs are being used by and for what reasons. This illustrates the necessity of the empirical studies of enhancement already being undertaken. Further, it suggests the need for more in-depth quantitative, qualitative and interpretive research (informed by relevant theoretical and conceptual literatures from the medical humanities and social sciences) that can attend more precisely to the contextual issues we believe are so necessary to integrate into bioethical deliberation, and which have begun to be charted by the authors discussed above.2 3 10 29 71 72

Conclusion

Our aim in this analysis has been twofold. First, and most importantly, in common with scholars like Coveney, Morrison, Singh and Vrecko, we want to more firmly fix the attention of the empirical medical humanities and social sciences to the objects, bodies, subjectivities and discourses that populate debates around the enhancement of human bodies and minds. Our hope is that this can be achieved in ways that are not dismissive of traditional normative analysis or the debates around autonomy and responsibility that are so prevalent within bioethics, but which nevertheless uncover new territory for empirical exploration and theorisation. Indeed, perspectives from the wider medical humanities and social sciences can, we believe, also be brought to question the very terms through which bioethicists, policymakers, entrepreneurs and others are currently framing and advocating their positions and movements (eg, as enhancement ‘bioconservatives’ or proponents). Examining substances and devices that some regard as having the capacity to enhance human bodies and cognition can inform our understandings of the interactions between biomedicine and society more broadly, and hence, represent important case studies for scholars in cultural studies, history, law and STS, to name just a few disciplines.

Second, in mapping the terrain that the empirical medical humanities and social sciences might chart (and, indeed, have begun to explore), we want to make a renewed call for the importance of drawing the expertise of these scholars into the spheres of policy-orientated bioethical decision-making (and potentially disrupt them). We recognise the quality and rigour of many contributions from philosophers and others to understandings of enhancements in society; nevertheless, we suggest that a still more nuanced understanding of these issues, incorporating (or at least, drawing on) the expertise of other humanities scholars and of social scientists, might further enrich bioethical discussions. We believe that the appraisal and analysis of any new sociotechnical practices associated with enhancing human capabilities must be constituted through sensitivity to the larger historical, cultural and political context within which they find form—and likewise should be sensitive to how technologies of enhancement might reconfigure those contexts.3 6 8 10 73 Key here is research that engages a range of publics with decision-making around enhancements.74 75 In so doing, there is an increased likelihood that recommendations can be reached which resonate with the lived experiences of policymakers, scientists, clinicians, patients and a range of other users. Accordingly, workable solutions to the governance of contested drugs and devices associated with enhancement might more readily be achieved.

Acknowledgments

Footnotes

References