Veljko Dubljevic

There is a growing literature in neuroethics dealing with the problem of cognitive neuroenhancement for healthy adults. However, discussions on this topic have tended to focus on abstract theoretical positions while concrete policy proposals and detailed models are scarce. Furthermore, discussions tend to rely solely on data from the US, while international perspectives are mostly neglected. Therefore, there is a need for a volume that deals with cognitive enhancement comprehensively in three important ways: a) with conceptual implications stemming from different points of view; b) with ethical, social and legal perspectives that would not be limited to one part of the world but reflect on the current situation in countries in Africa, Asia, Australia, Europe, North America and South America; and c) with discussions of concrete law and policy options. Contributors for the conceptual implications section will elaborate an important general issue (e.g. ethical acceptability of direct-to-consumer-marketing in case of cognitive enhancement drugs). Contributors for international perspectives section will provide a clear discussion on normative issues and cultural values, along with an analysis of empirical data on public attitudes on cognitive enhancement and/or prevalence (specific to the country in question). Contributors for law and policy section will offer a justification for the general policy type they argue for (1. prohibition, 2. discourage use, 3. laissez-faire, 4. encourage use, and 5. mandatory use) in the case of specific cognitive enhancement measure. Furthermore, they would evaluate the possible impact of a detailed regulatory model on consumption and demand, fairness in competitive settings and the social pressure to enhance.

This paper examines the claims in the debate on cognitive enhancement in neuroethics that society wide pressure to enhance can be expected in the near future. The author uses rational choice modeling to test these claims and proceeds with the analysis of proposed types of solutions. The discourage use, laissez-faire and prohibition types of policy are scrutinized for effectiveness, legitimacy and associated costs. Special attention is given to the moderately liberal discourage use policy (and the gate-keeper and taxation approaches within this framework), as many authors presuppose that this type of policy would best serve public interest. Different more or less articulated models in the taxation approach (Tobacco regulation analogy, Coffee-shop system, Regulatory Authority for Cognitive Enhancements and Economic Disincentives Model) are analyzed from the point of view of justificatory liberalism. The author concludes that prohibition and laissez-faire types of policy would neither be effective nor justified. A moderately liberal public policy shows more promise, but not all approaches within this type of policy would be legitimate and effective. The “gate-keeper” approach and related models could not be justified whereas approach based on taxation with suitable models might be legitimate and effective.

In my target article, I analyzed available information and policy options for the two of the most commonly used cognitive enhancement (CE) drugs: Adderall and Ritalin. I concluded that for all forms of amphetamine, including Adderall, and for instant-release forms of methylphenidate, any form of sale beyond prescription for therapeutic purposes needs to be prohibited, while some form of a taxation approach and the economic disincentives model (EDM) in particular could be an option for public policy on extended-release forms of methylphenidate. However, there has been a considerable amount of constructive criticism regarding my proposal. Some neuroethicists objected to my favoring prohibitive policies to dangerous CE drugs such as amphetamine and argued for laissez-faire or even mandatory use of enhancements. 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. Furthermore, there are those that think my argument in general and EDM in particular are failing to address the relevant issues in regulation of CE, such as social justice and real autonomy. Finally, there are those who offer suggestions on how the argument and the model of public policy for CE drugs can be improved. These comments are greatly appreciated, and I hope that my responses have captured the issues they were concerned with.

The authors interpret the data to mean that patients think that their physicians should make relevant decisions in Learning Health System based trials, and label that as being of 'utmost importance'. However, the patients themselves (in the excerpts provided) emphasize that trust in physicians is instrumental for obtaining protection of patient's bests interests (which seems to be of utmost importance for patients). Furthermore, the perceived bias regarding outcome certainty deserves more discussion. Namely, the decision to defer to physician's opinion is linked to perceived certainty of best clinical outcomes and instrumental for protection of best interest, while it lacks appreciation of the level of uncertainty that exists in clinical decision-making. Finally, a discussion on what are the implications of patient perspectives for individual, vs. relational autonomy is something the authors don't pursue, but instead use "physician-patient autonomy" throughout the paper.