I became interested in neuroenhancement because it’s being explored and talked about as an experimental treatment for mental illness. I was lucky with my own mental problem and got some expert help, but I have met many people with OCD and other disorders who have been less fortunate. It’s not surprising that some of them are reaching for what might appear desperate measures.
Treatment for OCD and other mental illnesses is better than it used to be, but progress has stalled in recent years. Most tend to take a two-pronged approach and combine drugs, which alter brain chemistry, with psychological therapy, which encourages people to confront and challenge attitudes, thoughts and behaviours. Delivered properly and together they mostly work with most people most of the time. But there is plenty of room for improvement.
Particularly puzzling is the uneven response of patients to the psychological treatment, the so-called talking cure. Usually a type of cognitive-behavioural therapy, this tends to be offered as a series of sessions, perhaps a few hours a week for three months, typically in groups. It aims to make people aware of their own thought patterns, the bad cognitive habits, and introduce drills and behavioural responses to help overwrite them.
What puzzles and frustrates psychiatrists is that the benefits of cognitive behavioural therapy for OCD, depression and other mental disorders, come in fits and starts. Moments of clarity, epiphanies, ‘eureka moments’ – call them what you will – these spikes in improvement arrive at different speeds in different patients and at different times. Sometimes the benefit is fleeting and must be coaxed back, for others the change is more solid.
One reason that people might experience no benefit from cognitive therapy, and there are significant numbers of them, is that their brains are simply stuck. They could be slower to respond, the lock on the box could be tighter. And, in that case, perhaps a dose of a cognitive enhancing drug or a tickle of electricity could nudge them along, help their minds to unlock the change in state they are so desperate for.
Electricity applied to the brain of psychiatric patients conjures images of shock therapy; this ECT delivered as a quasi-punishment was made infamous by its depiction in One Flew over the Cuckoo’s Nest. Originally delivered without anaesthetic, the massive doses of electricity were intended to induce seizures, unpredictable and uncontrollable storms of electrical activity in the brain. The muscles on the other end of the connecting nerves, baffled by the blizzard of messages from the brain, would convulse and the unfortunate patient would thrash about, often breaking arms and legs. Why induce seizures to treat depression or psychosis? The same reason that the most common advice from computer experts is to turn a crippled machine off and on again. It’s the reset button, the control-alt-delete of the mind.
ECT is still out there and is used, with some reported success, to treat depression. But it’s extreme and unpopular. The electric currents psychiatrists experiment with today are milder, and aim at a different target. Rather than simply reset the whole of the brain, psychiatrists now think electricity could help fix individual bugs. Applied directly to the scalp, the activity of the brain regions immediately below, they believe, can be turned up and down, even on and off. If – and it’s a fairly big if – a mental disorder can be traced to unusually high or low activity in an accessible part of the brain, the theory says, then this new form of electrical control should help to relieve symptoms. It might help to unlock activity in the brain, to release some latent potential. It might help more people discover relief.
Mild electrical current passed through the skull into the brain in this way has been used to try to treat people with numerous mental problems in recent years. The results are encouraging, if hardly conclusive. There are plenty of reports of near-miracle recoveries. In at least one case, the experimental treatment has been given to a pregnant woman to avoid the possible complications of psychoactive medicines like anti-depressants. Such case studies are interesting, but subject to a unique type of academic bias: reports of dramatic recoveries get written up and published, while patients who have the same treatment but don’t improve are quietly forgotten. If doctors and surgeons get to bury their mistakes, psychiatrists and clinical psychologists can simply hide their failures in a desk drawer.
Controlled studies and trials are rarer, but are starting to happen. A review of studies published in 2016 found good evidence that electrical brain stimulation could help reduce the symptoms of depression and schizophrenia, and promising early signs with eating disorders, anxiety, obsessions and compulsions.
Published in the Journal of Psychiatric Research, the article concluded that repeated doses of the electrical therapy can, ‘ameliorate symptoms of several major psychiatric disorders’. But it warns, ‘The field is still in its infancy and several methodological and ethical issues must be addressed before clinical efficacy can truly be determined’.
Not everybody is heeding the warnings. Under the conventional medical model a new treatment – an experimental drug, say – is checked in clinical trials, usually with hundreds of people, to make sure that it’s both safe and effective. Until it’s approved, the drug is off-limits to the people it is intended to help. That’s not the case with electrical brain stimulation. It can be done with one battery – typically one of the chunky ones from a smoke alarm – some wires and a bit of knowledge or instruction. As word spreads, and scientific and medical journals fill up with positive case studies, a growing number of people with OCD, depression, bi-polar disorder – desperate people who might have struggled to get good conventional treatment or for whom it didn’t work – are finding ways to experiment with electrical stimulation themselves, to manipulate the workings of their own disordered brains. Some equally desperate parents are doing it to their children to try to lift the social veil of their autism.
It’s not just mental disorders. Other malfunctions and misfiring circuits in the brain can be targeted with electrical stimulation too. In 2013, pupils at a special needs school in London had their brains gently massaged with electricity to see if it could help overcome their learning difficulties. Half a dozen eight-to-ten-year-olds who struggled badly with maths were given nine sessions of twenty minutes’ electrical stimulation at Fairley House School, with a special cap fitted to their heads. Compared to a parallel group who wore similar caps, but with the current switched off, the brain stimulation helped them score significantly better at general maths tests.
As these studies are reported and discussed, so the use of neuroenhancement leaks beyond medical applications, and into broader society. One thing these new neuroscience techniques have in common – unlike, say, cosmetic surgery – is that they do not try to introduce anything new. They seek to release or switch on some brain potential that is already in there. That means the growing number of people who turn to these techniques are using them to find and release some hidden power within. And as they do so, they follow in the footsteps of many, many people who have gone before.
The British cyclist Tom Simpson wanted to find and release some hidden power. He wanted to find the ability to win the world’s most famous bike race, the Tour de France. So, one summer’s morning in 1967, he took some amphetamine pills, washed them down with brandy and headed up one of the most difficult climbs of the cycling world: Mont Ventoux in Provence. He never made it to the top.
A couple of months after I got the results from Mensa, I cycled past the memorial erected to mark the death of Tom Simpson on Mont Ventoux. Actually I passed it twice – once very slowly on the way up and once very quickly on the way down. It’s at the side of the road a few hundred metres from the summit. A brutal oblong affair, it’s decorated not with the usual flowers and handwritten messages but with two shelves of cyclists’ colourful water bottles; the monument is entirely fitting for the surroundings. Part of the reason cyclists fear Mont Ventoux is its upper slopes are stripped of vegetation and exposed to frequent gale-force winds. The broken limestone landscape looks like snow from a distance and the surface of the moon close up. A giant red-and-white tower sits on the top and mocks as you will it to grow larger and nearer with every pedal turn.
In 1967 the amphetamines in Tom Simpson’s body stopped him sweating. As he pushed towards the top, he simply overheated. Delirious, he swerved from side to side. When he fell off, he famously asked the spectators to put him back on his bike. As he slipped from the saddle for the final time he was silent.
Simpson’s death caused much soul-searching among professional cyclists, many of whom at the time were taking the same kinds of drugs and stimulants. Together with new rules on what kind of help was allowed – and what for the first time was to be banned – it pushed riders and other athletes towards a new form of doping, based on science and new medicines.
We have long seen this kind of mission creep from treatment to enhancement with medicines designed and developed to fix the sick, but which were then exploited to boost the physical performance of the elite. Athletes doping in endurance sports are now the most visible example. Anabolic steroids abused to build muscle were first developed to stimulate growth and appetite in people with wasting conditions including cancer. Synthetic erythropoietin (EPO) – the banned substance of choice for cyclists in recent years – is used to treat the anaemia that often emerges as a complication of kidney and bowel disease.
Despite rules and regulations designed to stop the wider take-up of medicines by healthy people to enhance, it has proved unstoppable. And the same applies to neuroenhancement techniques being investigated and developed to treat mental illness.
Like many fringe and pioneering technologies in the past that subsequently became mainstream, at the moment the subject of neuroenhancement is most thoroughly discussed as science fiction. The best example is probably the 1966 book Flowers for Algernon by Daniel Keys. It’s written as a series of entries in the diary of Charlie Gordon, a mentally disabled floor cleaner turned into a genius by an experimental treatment. As his cognitive abilities increase, he takes over the research project that transformed him, and calculates with dismay his new-found brain power will soon start to fade. (Algernon is a mouse who was given the treatment first and shows a vividly similar rise and collapse in brain power that is ultimately fatal.) As Charlie’s selfawareness grows with his intelligence, he becomes angry and then ashamed to realize that, before the treatment, the people he thought were his friends had in fact ridiculed him.
‘How strange it is,’ Charlie writes, ‘that people of honest feelings and sensibility, who would not take advantage of a man born without arms or legs or eyes – how such people think nothing of abusing a man born with low intelligence.’ The story was turned into a 1968 film Charly, which won its star Cliff Robertson a best actor Oscar.
A less critically acclaimed yet still commercially successful film, Limitless, was also based on a book; The Dark Fields, published by Alan Glynn in 2001. It follows the upturn in fortunes of Eddie Spinola after he starts taking an experimental drug to increase his intellectual, creative and learning powers. After finishing his book in a couple of days, he embarks on a lucrative new career in finance. Eddie’s transformation is driven by a new ability to see patterns, often in large amounts of information.
‘My abiding impression of the period is how right it felt to be so busy all the time,’ Eddie says. ‘I wasn’t idle for a second. I read new biographies of Stalin, Henry James and Irving Thalberg. I learned Japanese from a series of books and cassette tapes. I played chess online and did endless cryptic puzzles. I phoned into a local radio station one day to take part in a quiz, and won a year’s supply of hair products. I spent hours on the internet and learned how to do various things – without, of course, actually having to do any of them. I learned how to arrange flowers, for example, cook risotto, keep bees, dismantle a car engine.’
A trilogy of decent fiction about cognitive enhancement is completed by Understand, a 1991 short story by Ted Chiang. It features another experimental drug, this time given to a man called Leon who suffers brain damage when he nearly drowns. The drug is intended to restore lost function, but ends up increasing his intelligence massively. Leon explains:
As my mind develops, so does my control over my body. It is a misconception to think that during evolution humans sacrificed physical skill in exchange for intelligence: wielding one’s body is a mental activity. While my strength hasn’t increased, my coordination is well above average. I’m even becoming ambidextrous. Moreover, my powers of concentration make biofeedback techniques very effective. After comparatively little practice, I am able to raise or lower my heart rate and blood pressure.
The three tales sound similar, but an important difference between them highlights a crucial point in the discussion of cognitive enhancement. Charlie is mentally defective and his quality of life suffers as a result. Society, many ethicists would argue, has a duty to intervene if it can. The same seems true for Leon, who loses quality of life and presumably will want it restored. But Eddie, the hero of Limitless, is already a relatively high achiever. Boosting his intelligence helps his bank balance more than his basic human rights. To help Charlie and Leon with cognitive enhancement is treating. But is using it to help Eddie cheating?
Bioethicists have pondered the distinction between treatment and enhancement for years with physical traits. When can a medicine be given to a healthy person, to improve them beyond natural limits? It’s not always easy to draw the line between the two. A common example of the dilemma describes the possible use of human growth hormone therapy for two boys of below-average height. One of the boys is short because he has a brain tumour which leads to a hormone deficiency. The second boy is short because he has short parents.
The conventional ethical model would give the growth hormone to the first boy only, because it would be labelled therapy. Giving it to the second boy would be classed as enhancement, and so not permitted. Sounds fair? Not for boy two. Various studies show being short can reduce the quality of life of men. They tend to suffer discrimination from women and employers. And what is therapy for if not to improve the quality of life?
Before Viagra was discovered to have its famous effect, no diagnosis of ‘erectile dysfunction’ featured in a doctor’s dictionary. If a seventy-year-old man was not as vigorous as he once was, it was a lifestyle and not a medical issue and fixing it was a bonus, an enhancement, not a treatment. The drug companies weren’t even looking for this solution – Viagra was meant to treat angina and hypertension. It performed poorly in this respect but an accidental side effect has made them billions.
Whatever definitions one attempts to impose on treatment and enhancement to keep them separate, logic has a nasty habit of pushing them back together again. If we regard treatment as a reversion to a ‘normal’ or ‘average’ state that would rule out heart transplants and the widespread use of statins to push the cholesterol levels in the blood of middle-aged men far below the levels possible otherwise.
This is more than just a semantic or philosophical issue. The difference between a therapy and enhancement determines real-world issues like price and access. With finite resources, the standard position is to prioritize therapy because it rights a wrong. But like ‘normal’, what is considered as ‘wrong’ constantly shifts as technology and expectations rise.
The ground becomes even less solid when the human improvements to be introduced – by both therapy and enhancement – are cognitive as well as physical, because ‘normal’ is much harder to define and because the likely benefits could have more day-to-day impact. As politicians are constantly telling us, we live in a knowledge economy. Knowledge is power. And a little knowledge remains a dangerous thing, especially if a political, military or economic rival has a little more. Or if they are just a little quicker on the buzzer.
In autumn 2012, I got an email out of the blue inviting me to appear on a special Christmas series of the television quiz show University Challenge for graduates. I am still not sure how they chose me, there seemed to be a suspiciously high number of journalists, but I was careful to reply and say yes before they realized their mistake and changed their mind.
University Challenge is famous partly because the questions are often so baffling even hearing the answer is no help to answering them, and partly because the teams are presented on screen one on top of the other. (It turns out, I learned on the day, that for one ill-fated series the producers did actually build the set like that.)
I learned something else from that day: the face I pull at the frustration of knowing an answer but not knowing it quickly enough, or of not being able to drag it from my memory at all.
I knew the phrase, A dog is for life and not just for Christmas, which was an answer to one of the questions. I had seen it plastered across enough car stickers in my childhood for the words to be lodged in my brain somewhere. I knew Georgia is the US state just north of Florida. Yet in both cases, when the moment arrived, I couldn’t give Jeremy Paxman the answer.*
Would it be cheating if a little burst of electricity to my ageing brain, or the improved recall of a smart drug, had helped me remember? Advances in neuroscience mean this isn’t a purely theoretical question. Scientists in New York have shown that electrical brain stimulation of a region called the anterior temporal lobe can improve the scores of students in general knowledge tests, presumably because it helped them to recall the answers to questions such as: what is the largest organ of the human body? (Answer – the skin.)
It is really ‘enhancement’ to help students to recall stuff they already know? If it is, then is this type of cognitive manipulation any different from the effects of a cup of strong coffee? Or the Pro Plus caffeine tablets we lived on as students a few years ago? Or the effects of a balanced and nutritious diet, no booze and a good night’s sleep?
It quickly drifts from a scientific to a philosophical question, and one that returns to the debate about how to define intelligence. Is cognitive ability what we know, or what we do? Is intelligence storing information or using it? Certainly, tests of intelligence take a utilitarian approach and measure actions. Academic examinations are more aimed at probing knowledge. The difference between the two is often not a question of varying intelligence but different personalities, or simple biochemistry. The use of knowledge, for example, can be tempered by nerves and shyness. Confidence can help people to express what they know. Drugs to calm anxiety and so help worried people show their ability in exams – or television quiz shows – are those cognitive enhancers? If so, is that cheating because it is unfair on the others? If it is, then what about the unfairness of scheduling the same exam in the morning rather than the afternoon, which will inevitably put some people at an advantage and others at a disadvantage, depending on their response to the daily yin and yang of circadian rhythms? Or should we assume better control over physiology is simply another sign and benefit of higher intelligence? It does, after all, help organisms to use what they’ve got to get what they want.
Opinions on what to do with cognitive enhancers, whether to control, allow, regulate, ban, recommend or even just research them, are all over the place at the moment. At one extreme there are people who call themselves transhumanists, who argue we have a right and even a duty to improve ourselves, and so society, as far as possible. The model for their neuroscience revolution is Leon Trotsky’s philosophy of constant upheaval.
More cautious are those who insist cognitive enhancers are risky and morally dubious. This camp includes administrators at Duke University in North Carolina who have banned the unauthorized use of prescription medicines like modafinil by students as cheating. Originally developed to induce wakefulness in those with narcolepsy and other sleep disorders, in healthy people it can improve focus, reaction times and fatigue levels, making it a student’s go-to study aid. If we ban these drugs then how long before students are required to wee in a bottle and be drug tested before every exam? And is it also cheating if they use them to study harder and longer in the weeks before but go into the exam ‘clean’?
If modafinil and other smart drugs can help students to focus so they can access stuff they have learned, the conventional argument says this is cheating, because other students haven’t been given the same help. But don’t smart drugs just help us achieve our potential, something which, after all, is one of the most commonly stated goals of education?
In fact, some evidence says modafinil could do what many people involved in education say they want: to give kids a fair and even start in life. The weaker someone’s cognitive performance to start with, the more modafinil seems to help them. Now there is an interesting ethical question. Smart drugs only seem fair to use if everybody has the opportunity to do so. But what if not everybody benefits to the same degree, and specifically, what if those with lower intelligence are brought closer to the rest? That sounds good at first, but it’s not hard to envisage some people unhappy about the shift – not least those who can currently seek the social and monetary advantages offered by an improvement in tests and exams by paying for private education.
Who should get to use cognitive enhancement? All who wish? Then what about the peer and competitive pressure placed upon classmates and work colleagues who would rather not, but know everybody else is? Or the more explicit pressure, from parents and bosses? Should we expect – and help – people who hold the lives of others in their hands to be at mental full speed the whole time? Pilots and surgeons make more mistakes when they feel tired. And judges have been shown to make decisions differently – they tend to grant more prisoners parole first thing in the morning and straight after meal breaks. For those looking to tip the scales in their favour, justice really is what the judge ate for breakfast. Should society not demand more equal treatment, and if cognitive enhancement can help to achieve it, then shouldn’t we do it? Don’t we have an obligation to do so?
But, on the other hand, if we expect people to pass professional tests and exams – to fly a plane or know their way around a burst appendix in a hurry – and they choose to meet those standards with some artificial help, then what happens if they decide not to take those same smart pills for a while? Does that invalidate their accreditation and remove their mandate, and if so, how is it different to a doctor who wakes up groggy after a party but decides to go to work anyway?
That’s a lot of questions and not many answers. All we can say with any confidence is that cognitive enhancement is not going to go away. Smart drugs like modafinil, already available to anyone with an internet connection and a PayPal account, are just the beginning. In the background, scientists and drug companies are working away on improved, more effective cognitive enhancing drugs. And so the ethical questions above, as well as more fundamental scientific issues such as long-term safety and the reliability and magnitude of the effects, are essential to explore.
So, to explore them myself, I found a website that offered to sell me some black-market modafinil. I gave them my credit card details and ordered some.
* Our team won, but not with a high enough score to proceed to the next round.