by By Emma Moody and Rudi Stanislaus-Carter
posted on 1st May 2013
Emma Moody (Upper 6th, Dollar Academy, Scotland), and Rudi Stanislaus-Carter (first year PhD student, St Andrews University) give their reaction to the 16th Annual Jeeves lecture at the School of Psychology & Neuroscience, University of St Andrews. The lecture, given by Professor Barbara Sahakian (Department of Psychiatry, Cambridge University,) was entitled: The Impact of Neuroscience on Society: The Neuroethics of ‘Smart Drugs’.
Following the lecture, Professor Sahakian signed copies of the book she has recently co-authored with Dr Jamie Nicole Labuzetta: Bad Moves: How decision making goes wrong, and the ethics of smart drugs (OUP, 2013).
On Friday, April 5th 2013, Professor Barbara Sahakian visited the School of Psychology & Neuroscience at St Andrews University to deliver the Jeeves Lecture. Due to its accessible content and interesting title, the lecture attracted a large and diverse audience, including members of the department, students and the general public. Professor Sahakian discussed the use of drugs such as Ritalin and Modafinil, and presented data supporting their positive effects on cognition. There was a strong focus on their use in healthy participants to improve performance, in addition to those who have a clinical need (e.g., people with Attention Deficit Hyperactivity Disorder (ADHD)).
This was particularly interesting from Emma’s perspective as a secondary school student – with impending exams! – who, during the Easter break, was shadowing the work of Rudi, a first year PhD student in Professor Verity Brown’s lab. Rudi’s research involves training rats to perform a vigilance task. When they are trained, she will compare their baseline performance with performance after lesions to the thalamic reticular nucleus, an area thought to be important in attention. Understanding the brain basis of attention has direct implications for treating the types of disorders that Professor Sahakian discussed throughout the talk. With translational research being the primary goal, it was particularly interesting for Emma to learn about some of the implications of this research.
The lecture discussed the use of the drugs, methyphenidate (Ritalin®), atomoxetine (Strattera®) and modafinil (PROVIGIL®) as cognitive enhancers by both patients with brain disorders and also by healthy people. Of the three drugs, Professor Sahakian showed that modafinil was the most effective across a variety of cognitive domains: due, in part, to its effects on multiple neurotransmitter systems including acetylcholine, noradrenaline and dopamine. She showed data to indicate that the enhancing effect was seen in both clinical populations such as those with ADHD and schizophrenia, as well as young and aging adults. More specifically, a student working with Professor Sahakian had shown that the effects of modafinil dose-dependently improved planning and problem solving in healthy volunteers – and the effects were especially prominent in cognitively demanding tasks. Alongside the scientific and clinical advances afforded by modafinil, Professor Sahakian suggested its use was particularly valuable at times when greater cognitive functioning is required. For example, people working shifts (e.g., doctors) who might also work long hours and have a disrupted sleep pattern. The importance of restorative sleep is well documented and lack of sleep could impede maximal performance – this is something that could be corrected through the use of such drugs.
After discussing the scientific evidence for the drugs’ efficacy, Professor Sahakian went on to discuss the ethical implications: “Modafinil shows great promise for helping patients in psychiatric and neurological populations … The real controversy lies in the use of modafinil as a cognitive-enhancing medication for healthy individuals” (Sahakian & Labuzetta, 2013, p.99). Although she advocated the individual’s liberty to use the drug, she highlighted paediatric use as a particular ethical issue and questioned whether a child could make an informed decision. Professor Sahakian also raised the serious issue of understanding potential negative effects on the developing brain as compared to that of an adult.
What was perhaps most interesting for us was the discussion relating to side-effects. Aside from a brief remark in the lecture about the cardiovascular side-effects in older patients with higher dosages, it was not until the questions after the talk that side-effects were raised. It seems remarkable that modafinil, a so-called ‘dirty drug’ in terms of its pharmacology, has so few side-effects, or at least few side-effects that we are aware of. Professor Sahakian said that more research is needed to determine the long term consequences of chronic use for both psychiatric and healthy populations. A drug with no immediate or obvious serious side-effects is an important aim from a psychopharmacological perspective. However, a lack of side-effects could also, paradoxically, be a cause for concern: if there are side-effects, a cost-benefit analysis ensures that drugs are only given to those for whom the negative consequences are mitigated by the potential benefits. Decisions are therefore driven by the relative need of the patient as opposed to the desires of a healthy population. A lack of side-effects appears to enhance the positives, possibly pushing people towards choices that they perhaps would not have made had negative consequences been an issue.
While there is still choice entering into the equation, it is easy to believe that cognitive enhancement could serve only to enhance society. Choice or want, however, are not synonymous with possibility. Given that drug companies spend millions in drug development, the price of the drugs might mean that being able to take them on more than infrequently could be a luxury afforded only to those with higher incomes. Rather than serving to reduce societal disparities, this could widen the gap – giving those who are already considered to have an advantage, an even greater one. Nevertheless, there could be many additional positive outcomes associated with commercial use, as is already seen in the military. There is a distinct difference between the abuse of the drugs by students cramming in last minute revisions, and its use, for example, by soldiers to improve accuracy and safety in defence.
One thing that struck us was that when these issues are considered amongst academics with common backgrounds and knowledge bases, it is possible to discuss them without always analysing the implications of every statement. However, once these ideas are in the public domain there is no way to control for individuals’ backgrounds, or the way in which they intend to apply their own conclusions or understanding of the material. This inability to effectively control public response to, or at least understanding of, significant material means that, as scientists, we have a special responsibility when discussing such research. Indeed, the approach by Professor Sahakian was appropriate given that the majority of the audience was involved in the field, but one needs to be careful when approaching a wider demographic. Perhaps for this very reason, our reactions to her talk and the topics we highlighted reflect our cautiousness. This caution is reflected in a new book, co-authored by Professor Sahakian and neurologist, Dr Jamie Nicole Labuzetta: “Bad Moves: How decision making goes wrong, and the ethics of smart drugs” (OUP, 2013). In the book, the authors highlight that they want to stimulate discussion and consider both sides of this controversial issue. Although the benefits of cognitive-enhancing drugs and the empirical evidence supporting modafinil’s efficacy are discussed throughout the book, the authors remain cautious about advocating a more widespread use by healthy people.
We both came away from the lecture with a strong conviction that this is a debate that must be heard more widely, in order to enable people to make informed choices based on both sound scientific evidence as well as ethical principles. The potential ramifications for society are so paramount that they must not be allowed to be marginalised. The essence of translational research is the progression of scientific evidence (“from the bench”) to valued application (“to the patient’s bedside”). What must not be forgotten by the scientists at the bench is that there is a patient in the bed. In other words: it is people who both perform and benefit from scientific advances, and people need to ask the pertinent question: is PROVIGIL® (modafinil) destined to be the new-and-improved Pro-Plus® (caffeine) and are we ok with that?
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