In preparing for law boards, Tiffany struggles to master huge amounts of material while teaching biology in high school. She hopes to pass and join a law firm.
For a week before the exam, she takes modafinil, obtained legally from a sympathetic psychiatrist. Like Eddie Morra in Limitless, on modafinil Tiffany feels she can master anything and ace her exams (“a tablet a day and I was limitless,” says Eddie). Tiffany takes the exam on modafinil, but crashes afterward and misses two days at school. But with the aide of modafinil, Tiffany passes with a high score.
Did Tiffany do anything wrong? Dangerous? Risk becoming dependent on modafinil for success in stressful situations? Did she cheat when she took her exam on a drug that others had not taken?
Before answering those questions, consider the drugs people now take toward the same goal. Caffeine is currently the world’s most popular cognitive enhancer. If we include the caffeine in coffee, tea, cocoa, soft drinks, and energy drinks, billions of people every day ingest cognitive enhancers. Nicotine also stimulates the brain. French writers from Balzac to Sartre wrote while drinking pots of coffee and smoking packs of cigarettes.
If we could study enhancers in a calm, scientific way, we might discover better cognitively enhancing drugs. Although the effects fade over hours, caffeine is an addictive drug and desire for it builds over time. When people accustomed to several cups of coffee a day quit, they experience headaches and withdrawal. Although caffeine has proved to be remarkably safe, it also stimulates the heart, so we need a more selective enhancer, the way cyclosporine selectively inhibits rejection of transplanted organs. And of course, nicotine is customarily taken in products that damage the lungs and thus cause cancer, so people need a substitute for it.
Modafinil is known more commonly by its first trademarked name, Provigil. Not an amphetamine, modafinil stimulates wakefulness and allows its users to get the same effect on four hours as on eight hours of regular sleep. Originally created by a French company to treat narcolepsy, modafinil has been used in the last decade to fight chronic fatigue syndrome. Physicians also prescribe it for sleep-shift workers, soldiers who need to stay vigilant on long missions, sleep apnea, and for the “brain fog” that often accompanies chemotherapy or coronary bypass surgery.
Modafinil is not harmless and has not been tested in large general populations. In heavy dosages, modafinil causes dermatological problems such as acne and eczema. It suppresses appetite, causes insomnia, headache, nausea, nervousness, and hypertension. It increases wakefulness and it may increase ability to focus.
The FDA approved Provigil for Cephalon in 1998. Nearly a decade later in 2006, Cephalon tried to get Provigil approved under the name of Sparlon to treat Attention Deficit and Hypersensitivity Disorder. However, the medical committee advising the FDA discovered that some patients using modafinil developed severe skin rashes. Concerned that Sparlon might be marketed to far more adults than Provigil, even adolescents and children, the committee voted twelve-to-one against it.
Scientists do not know exactly how modafinil works, and the fact that it is not thoroughly studied or understood should warn us about its potential dangers. After all, cocaine and amphetamines were once thought to be neither dangerous nor addictive.
Amphetamines stimulate everything in the central nervous system, including the heart rate, whereas modafinil selectively stimulates wakefulness without causing hyper-alertness, heart palpations, or nervousness. Modafinil increases histamines in the hypothalamus and the release of neurotransmitters called monoamines.
The FDA has monitored modafinil’s usage for over a decade, and it requires that physicians report all adverse events from such usage, which includes suicides, skin reactions, and other harms. So far, few such events have been reported. At this inchoate stage, it may not be addictive like amphetamines (although at least two researchers disagree[1] ). Thus, use of modafinil may be physically safe for competent adults. As said, there have been no systematic studies of its widespread usage over decades.
The FDA approves a new drug for one purpose—the official one on the drug’s label—and then physicians informally may test it for other purposes by prescribing it “off label.” It is not clear how often physicians report adverse side effects of off-label drug usage, so this could mean more people have problems than have been reported.
All this seems less revolutionary when we realize that large amounts of caffeine may create alertness just as effectively as modafinil. In fact, caffeine is a more potent cognitive enhancer than many people realize, and people may take far more of it than they admit.
The Center for Science and the Public Interest says that a 16-ounce (Grande) serving of Starbucks coffee contains 320 milligrams of caffeine. In contrast, a 12-ounce can of Jolt Cola contains 72 milligrams of caffeine; Diet Coke contains 47 milligrams of caffeine.[2]
Consider this interesting fact about caffeine. In groundbreaking research, Li-Huei Tsai of MIT developed a quick way to mimic Alzheimer’s-like symptoms in mice and an innovative method to test memory in these mice. According to the NOVA show that featured Tsai’s benchmark-to-bedside research, another study found that giving the same kind of mice the equivalent of five cups of coffee a day for two months allowed them to recover the same memories.[3]
Maybe caffeine is already as good as modafinil for helping the brain. Like aspirin, it may be more efficacious than scientists realize. If aspirin and caffeine had not been discovered, either today as new patented drugs would make billions for pharmacological companies. Use of both has been proven effective and safe.
Given the data indicating safety, should competent adults such as Tiffany be allowed to take modafinil not for any quasi-medical dysfunction but simply to increase her performance? Let’s suppose it’s easy for Tiffany to get a prescription for modafinil, no harder than it is now to get one for a tranquilizer such as lorazepam, an antidepressant such as flouoxetine, or for the five million who take them, Ritalin or Adderal. Even if they must see a physician every month for monitoring, many people find these drugs easy to get.
This is not one of those notorious desert island cases of some philosophers. A 2008 online survey of the journal Nature revealed that an astonishing 20 percent of readers had already taken one of three legal drugs to enhance their mental abilities (methylphenidate, modafinil, and beta blockers, e.g., atenolol).[4] Donepezil, marketed under one trademark as Aricept, prevents the decline of memory in patients with early stages of Alzheimer’s disease. Some researchers think the same drug used on the same neural pathways, which increases concentration of the neurotransmitter acetylcholine, will increase memory in healthy people, and take donepezil to enhance their brains.
Whether it’s modafinil or Virtual Life, the key philosophical question becomes: Is it intrinsically wrong to use these mental enhancers?
To emphasize what kind of question I am asking, notice that using cognitive enhancers could be indirectly wrong because of many reasons: they might not work, making them a waste of money; they might have dangerous effects that we might not know for many years (modafinil might cause brain tumors); they might lead to greater inequality; in using them, we might lose something important in society; using them might later harm others; or their use might send the wrong message to disadvantaged groups.
But I am not here asking any of those questions. Instead, I am asking whether it could be just wrong to employ cognitive enhancement. In other words, is it morally forbidden to try to change my self, my memory, and my brain? Is changing myself this way wrong in itself, something I have no right to do? Am I obligated not to do this? Am I an evil person if I try to grow my mind, not through education or meditation, but biochemically, or with machines, or by escaping this world? If I’m successful, am I a freak?
Suppose Hannah takes modafinil to increase her performance to do the New York Times crossword puzzles, puzzles that grow harder as the week progresses. At the end of the week, if Hannah has worked all the puzzles for the first time in her life, should she be elated? Critics would say that modafinil, not her authentic self, worked the puzzles. But Balzac wrote his great novels using caffeine and nicotine, so are his works suspect? Admirers would say that modafinil focused the resources of Hannah’s and Balzac’s brains, allowing them to function maximally.
Nevertheless, naturalistic intuitions nag us that Hannah cheated. If she can’t finish the puzzle “herself” and can only do so on a drug, has “she” really finished it?
John Stuart Mill in On Liberty wrote:
The only part of conduct of any one, for which he is amenable to society, is that which concerns others. In the part, which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.[5] (emphasis added)
On Mill’s view, my enhancement of my mental life could only be wrong, could only be a moral issue, if it threatens harm to others.
Such harms may exist, and we will examine them soon, but suppose we ask the solitary question of a financially secure, single adult with no responsibilities to children or aged parents, just an atomistic individual wishing to experience greater cognitive powers. So now we can ask the question in its purest form: is it intrinsically wrong for her to try to enhance her mental powers?
Enthusiasts can see no reason why it is. Just as it is not intrinsically wrong to work long hours by taking lots of caffeinated products, or to use the Internet all day at work in trading stocks, or to retreat after work into Virtual Life, nothing about better versions of these drugs, machines, or fantasies justifies calling them intrinsically wrong.
Indeed, Mill would put the onus of proof on any group or government that would limit a person’s freedom to change oneself. Why should there be any limits at all on what a person can do to improve his or her mind?
Bioconservative Alarmists argue that I do not have the right to change my brain because its special value comes from its uniqueness, from its being given to me by God and not manufactured, from its being natural, and from its being fundamental to who I am. In enhancing my brain, I risk changing my identity, and I should not do that.
Even if that’s true, isn’t it up to me to risk changes to my identity? For most kids, going off to West Point or to a big sports-obsessed, fraternity-dominated university risks a change of identity, but can’t people make that decision?
Going back to factors that enhance thinking, neuroscientist, Enthusiast, and dissenting member of the President’s Council on Bioethics Michael Gazzinga argued, “What is the difference between Ritalin and the Kaplan SAT review? It’s six of one and a half dozen of the other. If both can boost SAT scores by, say, 120 points, I think it’s immaterial which way it’s done.”[6]
Alarmists object that mental enhancement is to gain an edge, not to fend off death. But let us take that objection, give it some rope, and see if it hangs itself. Now, of course, we are sidestepping the view that using enhancements is intrinsically wrong, and moving to indirect arguments.
In most walks of life—academia, finance, law, engineering, medicine, and computers—losing mental acuity is a kind of death. When the command goes, so goes the whole system. Consider the most plausible ethical situation where competent adults merely wish to maintain their normal mental functioning. Who can argue against, say, a tax accountant’s wish to continue providing for his family? If the stock market takes a dive and retirement accounts are wiped out, who would deprive similar professionals from working longer in order to accumulate adequate monies?
“Yes, but!” Alarmists retort, if you open that gate, too much goes through. To allow competent accountants to maintain maximal mental functioning into their eighties will also allow thirty-year-olds to improve their functioning. Patients in their thirties will claim they need the same enhancers to get a job and care for an aging parent, to compete in the world market, and so on. It will be a reverse slippery slope, with a tidal wave surging upward, pressuring everyone to take cognitive enhancers.
Well, that’s partly true, although not all baseball players take steroids. Moreover, Enthusiasts retort, this objection ignores the likelihood that productivity, creativity, and pleasure could also increase dramatically. Few people would enter a time machine and return to a time when they couldn’t use the Internet to find medical information or use a phone to call friends. If tens of millions could safely use modafinil, who knows what new knowledge might be discovered, what new music created, what new theorems proved?
Nevertheless, perhaps the benefits to the general public would not be as great as Enthusiasts hope. Studies to date of the benefits of modafinil suggest small benefits and are limited to small studies of a few people. It could be that the smartest, most creative people get the most benefit, or the dullest, but not average people. Compared to the brain-boosting effects of computers and caffeine, the extra boost from modafinil might be small. It’s not going to change Forrest Gump into Einstein.
However, Alarmists have another trump card in their hand here. As in the first chapter, the unmentioned elephant in the room in this discussion is addiction. Addiction should be distinguished from dependence. Addiction is biochemical, where because of increased tolerance to the drug, users need more and more of the same substance to achieve the same effect. Dependence is psychological, becoming habituated to using the drug to perform a task and feeling incompetent to do it without it.
New research suggests that the thrill of certain kinds of experience releases dopamine in the brain, which produces a kind of feedback loop much like that caused by opium or cocaine.[7] Thus, wins in gambling or sexual conquests release chemicals that could be just as addictive as alcohol, caffeine, or heroin.
An important issue about addiction to mind-enhancing chemicals is the Exposure Effect. If you legalize the sale of alcohol in a previously dry county, a percentage of that county’s previously teetotaling citizens will become heavy drinkers or alcoholics. Ditto with gambling.
Alarmists correctly predict that with greater exposure to the Internet, smart phones, Starbucks coffee, or modafinil, more people will become dependent/addicted on these cognitive enhancers. This is both because people like acting smarter and because biochemical changes take place with the rush of mental victories.
Alarmists emphasize that the dangers of addiction to new brain enhancers are real. At Princeton’s Institute for Advanced Study, the Hungarian Paul Erdös, one of the most gifted and prolific mathematicians of the twentieth century, abused amphetamines, but used them to prove many theorems in mathematics. According to one biography of Erdös, to win a bet that he could not, Erdös once gave up amphetamines for a month. When asked if it had been worth it, he replied that during his abstinence, mathematics had been set back a month: “Before, when I looked at a piece of blank paper my mind was filled with ideas. Now all I see is a blank piece of paper.”[8] After he won the bet, he resumed using amphetamines. (He influenced mathematics so much that his friends, students, and followers assign themselves “Erdös numbers” to boast how much he directly taught them, with a “1” as the highest number.)
Does Erdös’s use of amphetamines devalue that achievement? Although such usage makes him a poor role model for teenage math prodigies, a proof is still a proof. However, the same mental powers involved in making proofs may have also given Erdös resistance to other dangers of amphetamine addiction. Also, as a Fellow of the Institute for Advanced Studies, he didn’t need to worry about money and thus, about paying for his addiction—an unusual circumstance.
Professional poker player Paul Phillips claimed that the use of modafinil and methylphenidate made him better and helped him earn $2.3 million playing poker. “The drugs improved my concentration during high-stakes tournaments,” he said, allowing him to better track all the action at his table.[9]
In a prequel to Limitless, Slate writer David Plotz planned to take 100 milligrams of modafinil for a week as an experiment and see how productive it made him and whether he slept well on it. To write on deadline, he took modafinil in the morning, felt like Superman for fifteen hours and did not want to go to sleep, but did anyway, woke up refreshed, worked another great fifteen-hour-day, but then, fearing he would become addicted, panicked, quit, and did not take it again.[10]
But let’s not downplay the damage of drug addiction, especially to mind-enhancing drugs. By 2000, an epidemic of addiction to methamphetamines had swept rural America and parts of the world, alerting us to the dangers of this drug. From the epidemic of abuse of amphetamines in rural America and Mexico, we’ve learned the hard way about the exposure effect. Even if only 2 percent of users in the general population became addicted to modafinil, that’s millions of harmed people.
Minnesota had so many convicts with “Dew mouth”—no teeth from excessive consumption of Mountain Dew and from grinding teeth due to agitation on methamphetamine—that whether to provide them with false teeth became an ethical issue of allocation of its limited state resources.[11] Many states have now taken steps to restrict sales of cold medicines containing ephedrine and pseudoephedrine, ingredients needed to make methamphetamine.
But modafinil is not an amphetamine, Enthusiasts retort. Indeed, it seems more like caffeine than amphetamine. Enthusiasts again pose a key ethical question: should we allow adults to use modafinil when many users might become dependent on it?
One compromise between Enthusiasm and Alarmism is to continue the present arrangement, allowing modafinil by prescription, and hence allowing it to be monitored, but not banned. This makes physicians gatekeepers of such drugs and decision makers about therapy, enhancement, and whether that distinction has moral relevance. Also, if modafinil turns out to be addictive and not just to cause dependence, then physicians could restrict prescriptions, or the FDA could declare modafinil a Class-III drug, subject to more careful monitoring.
This does not completely answer the question in public policy, which queries how common such prescriptions should be. Do we want to go down the road of Ritalin and Adderall, which five million American children now take? Or antidepressants such as Prozac and Zoloft, which another six million Americans take? In 2020, do we want four million American managers and professionals on modafinil?
Well, assume the big numbers, and assume that four million American adults do want to work on modafinil. Is that number in itself a reductio ad absurdum of expanded availability?
Yes, Enthusiasts argue, some harm will ensue, but so will enormous benefits, including satisfactions perhaps undreamed of by current thinkers. Although a small percentage of a normal population will become dependent, most people will handle modafinil, outgrow it, or choose to forego it when taking it conflicts with other values. That means that a cost-benefit judgment must be made between the good of increased mental performance by say, 98 percent of people, and the impairment of the addicted 2 percent.
Personally, I worry about something that neither Alarmists nor Enthusiasts commonly discuss. I worry that drug companies will push modafinil and its clones on people in hopes of creating golden cash cows—if modafinil could increase cognitive performance and retain its results, Big Pharma could make billions. But my hunch is that if it could produce such results, millions of people would be using modafinil now, the way people take anabolic steroids to build muscle mass and find physicians to write them prescriptions, and drug companies would be covertly promoting modafinil’s usage. The problem is that we don’t know, but my hunch is that modafinil will not have the same results in everyone, will not be that superior to caffeine, and will not help memory, but only focus.
If modafinil worked well, then I believe we would have an arms race and more and more productive people would need to take it. After all, if every other professor, physician, writer, lawyer, or engineer takes it and performs better than I, what choice do I really have? If I want to succeed, I must perform at the norm of my group.
Like Virtual Life and a fantasy life divorced from reality, the decision to take modafinil should be a personal one, but that does not mean we cannot rationally evaluate personal values. Personally, if I could only write books or papers on modafinil, I would worry that something is wrong with me. “Why can't I just write on coffee?” I would ask.
If I were Tiffany, I would have a nagging doubt that I could not have passed the Law Boards on my own, and that doubt might grow, making me less confident that I could do any big, intense project on my own. Such worries might make me hoard modafinil, lest my supply of the drug ever became interrupted.
And if Tiffany, or four million professors, became dependent on modafinil, what would happen if the supply did cease? If the FDA discovered it caused atrophy of the brain and revoked it? Or the pharmaceutical company, realizing people's dependence, doubled, then quadrupled its price? What if it became so expensive, or illegal, that people began doing wrong things to get it?
As a personal value, you can't start taking any drug with addictive potential with “eyes wide shut.” You must evaluate your own potential for addiction, whatever the potentially addicting substance or activity is. For me, coffee is enough.
“Addictive Qualities of Modafinil Not Discussed by FDA Advisory,” Alliance for Human Research Protection, March 28, 2006. http://www.ahr org/cms/content/view/130/28/
Center for Science and the Public Interest, “Caffeine Content of Food & Drugs,” 2007. http://www.cspinet.org/new/cafchart.htm
“Science Now: Of Mice and Memory,” NOVA, Corporation for Public Broadcasting, June 25, 2008. http://www.pbs.org/wgbh/nova/sciencenow/0301/bios.html
“Some Professors Pop Pills for an Intellectual Edge,” Chronicle of Higher Education, April 25, 2008, A1.
John Stuart Mill, On Liberty, 1869 (many editions).
James Hughes, Citizen Cyborg, 37.
Trevor W. Robbins and Barry J. Everitt, “Drug Addiction: Bad Habits Add Up,” NATURE, 398, no.15, (April, 1999).www.nature.com
“Paul Erdös,” Wikipedia, quoting from J. Hill’s Paul Erdös: Mathematical Genius, Human (In That Order).
Karen Kaplan and Denise Joshe, “Academics, Musicians, Even Poker Champs Use Pills to Sharpen their Minds, Legally,” Los Angeles Times, December 20, 2007.
David Plotz, “Wake Up, Little Susie: Can We Sleep Less?” Slate, March 7, 2003.http://www.slate.com/id/2079113/
“Mobile Clinic Treats ‘Mountain Dew Mouth’,” ABC News 20/20, February 13, 2009; “What is Mountain Dew Mouth?” WiseGeek,