








































© Equinox Publishing Ltd. 2008, Unit 6, The Village, 101 Amies Street, London SW11 2JW

[Expositions 2.2 (2008) 139–146] Expositions (print) ISSN 1747-5368  
doi:10.1558/expo.v2i2.139 Expositions (online) ISSN 1747-5376 

Framing Pains, Pills, and Professors

ANJAN ChAttErJEE

Department of Neurology and the Center for Cognitive Neuroscience 
University of Pennsylvania

Introduction

We are accustomed to anabolic athletes, medicated musicians and souped-up 
students. Now it appears that we can add pill-popping professors to this list 
(Sahakian and Morein-Zamir 2007).

“Cosmetic neurology” is the term I used to describe the practice of  
using neurologic interventions to improve movement, mood, and mentation 
in healthy individuals. The specific kinds of enhancements that might be 
possible and the ethical concerns (safety, distributive justice, coercion, and 
the erosion of character) they raise are detailed elsewhere (Chatterjee 2004, 
2006). Despite ethical concerns, I have argued that the practice of cosmetic 
neurology is likely to become widespread (Chatterjee 2007). This point is 
predictive, not prescriptive. It means, though, that it is likely less useful to 
discuss whether this practice should occur than to consider what form this 
practice should take. Sorting this out will prove to be quite difficult itself, 
because translating principle into practice runs up against the problem of 
conflicting reference frames that can alter one’s view of the practice. These 
multiple reference frames determine what it means to be a good person or to 
construct a good society.

I hope to illustrate the problem of conflicting reference frames by exam-
ining a special case, before returning to the issue that triggered this com-
mentary—that of pill-popping professors. The specific case, modulations of 
emotional systems to treat psychological pain, is of particular concern. There 
is an urgent need to ease the psychological burdens imposed by significantly 
traumatic events. Thousands of young men and women will experience post-
traumatic stress following our military adventures. Few would argue against 
treating such individuals. But what about less severe traumas? Beta-blockers 
may prevent minor post-traumatic stress symptoms when given in emergency 
rooms to individuals after car accidents. In addition to the use of medications 
to dampen the emotional effects of memories retrospectively, presumably 
medications might be used to dampen the effects of emotions prospectively 



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by affecting the encoding of memories. Assuming that such medications will 
be effective and others will be available in the near future, how widely would 
they be used? Presumably they might be used in all sorts of “normal” traumas 
such as break-ups in relationships and other disappointments that seem inte-
gral to our humanity. What would the long-term consequences be of flatten-
ing these bumps in the road with medications? Do we need pain to develop 
character? Beyond individual development, what is the role of pain in bind-
ing us communally? Empathy for the experience of pain in others may be 
mediated through the observer’s own neural pain circuits. If pain circuits are 
chronically dampened, then would an individual still be capable of empathy? 
Communally, would we be even more inclined to sanitize inflicting pain on 
others as damage collateral to the service of a greater cause?

In thinking through concerns around treating psychological pain, it is use-
ful to review how medical developments historically dealt with the treatment 
of physical pain. Uncertainties about how to treat physical pain appropriately 
are similar to uncertainties about how to treat psychological pain. The his-
toric trajectory of thinking about physical pain may anticipate the thinking 
about psychological pain (Chatterjee 2008).

Anesthesia for Pain
In the nineteenth century, significant medical advances made it possible to 
use anesthesia to ease the pain of surgery and of childbirth (Caton 1999). The 
pain of childbirth is particularly relevant in so far as this pain is “natural.” At 
the heart of objections to using anesthesia for childbirth pain was the social 
construction of the meaning of pain. treatment of pain was objectionable on 
three grounds: don’t mess with Mother Nature; spare the rod, spoil the child; 
and no pain, no gain. 

Pain as Natural
From the very beginning, some obstetricians objected to the use of anesthesia 
for childbirth pain because this pain was natural and interventions invited 
medical disaster (Caton 1999). The general worry was that we are not wise 
enough to anticipate the unintended consequences of these actions. Ether had 
significant dangers. Concerns surfaced that anesthesia might interfere with 
uterine contractions or directly impair the infant’s well-being when it became 
clear that anesthetics crossed the placenta into the infant’s circulation. how-
ever, the popularity of anesthesia continued to rise with support from the 
media and advocacy groups. Further medical developments making safety less 
of a concern also contributed to an increased use of anesthesia for childbirth. 



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The appeal of things natural remained and resurfaced with force in the mid- 
twentieth century. Grant Dick read promoted the natural childbirth move-
ment. he suggested that women were better off being conscious through the 
process and were emotionally fulfilled by seeing and welcoming the child as 
it emerged into the world. Around the same time, Lamaze published “Pain-
less Childbirth” promoting his own techniques of natural childbirth. In 1956 
Pope Pius XXII gave a special address on the moral value of natural child-
birth, giving these approaches spiritual weight. This address coincided with 
a period in which the public was less optimistic about medicine’s ability to 
alleviate illness and pain.

Pain as Punishment

Within religious traditions, pain is sometimes understood as a vehicle for 
atonement. In the Judeo-Christian tradition, the link between the pain of 
childbirth and punishment is made explicitly in Genesis (3:16). The Puritan 
minister Cotton Mather, who wrote a textbook of medicine and was an advo-
cate of inoculations for smallpox, declared that “[t]he sin of our first parents 
was the first parent of all our sickness.” The notion of pain and suffering as 
deserved is evident in other traditions. In the Oresteia, Aeschylus had the  
Furies declare that “every mortal who outraged gods or guest or loving parent: 
each receives the pain his pains exact” (Aeschylus 1977, 268). Self-infliction 
of pain as an act of atonement remains prominent in Christian, Muslim, 
and hindu traditions. While the view of pain as deserved punishment has 
its adherents in religion, similar views appear in secular writings. In colonial 
America, brutal public punishments were sanctioned to serve as both pub-
lic entertainment and education. relieving deserved pain was considered an  
invitation to social chaos.

Pain as Progress

Pain is also considered a vehicle for development. This development can be 
thought of in both individual and communal terms. In spiritual contexts, 
pain serves as a vehicle for transcendence. In secular contexts, pain builds 
character. Writers explored the experience of pain and suffering as integral 
to larger than life characters in literature, such as Prometheus, hamlet, and 
Faustus. hemingway claimed “[y]ou especially have to hurt like hell before 
you can write seriously” (quoted in Caton 1999, 211), a sentiment echoed by 
many others linking pain to creativity.

Pain also serves to strengthen social bonds. religious views that a God that 
punishes also heals give reason for communities to rejoice together in that 



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healing. In the context of childbirth, the traditional ways of delivery served to 
solidify social bonds. The pain of childbirth and the real possibility of death 
meant that neighbors and family and friends supported the event in a way 
that often formed life-long bonds.

Countervailing Reference Frames
Despite the various ways in which the treatment of physical pain was (and 
sometimes continues to be) viewed with mistrust, the use of pharmacology for 
pain management is now widespread. two ways of reframing the meaning of 
pain facilitated this change. The first was framing pain treatment as a mechan-
ical rather than a metaphysical manipulation. The second was framing pain 
treatment as one element of the humanitarian goal of relieving suffering.

The classification of pain as a biologic phenomenon diluted the impact of 
religious interpretations of pain. Very early in the use of anesthesia, Simpson 
divested the pain of childbirth of its religious interpretations. he empha-
sized that pain was a consequence of anatomy and not divine wrath. In the 
early twentieth century, Sherrington observed that complex behavior could 
be analyzed as a set of reflexes co-ordinated to carry out goals, and pain and 
our response to it could be viewed as a complex reflex arc. The discovery of 
different sensory receptors and the mediation of pain by specific pathways 
made explicit the possibility of manipulating that pain. This mapping of pain 
onto its biology helped frame its treatment as one more mechanical manipu-
lation. 

humanitarianism also contributed to reframing the meaning of pain. The 
goal of alleviating pain fell naturally into reform movements like women’s 
suffrage, abolitionism, prison reform, and child labor reform. Along with 
these movements, in the late nineteenth century, the public attitude towards 
pain shifted. As William James wrote, 

A strange moral transformation has, within the past century, swept 
over our Western world. We no longer think that we are called on to 
face physical pain with equanimity…. The way our ancestors looked 
upon pain as an eternal ingredient of the world order, and both caused 
and suffered it as a matter-of-course portion of their day’s work, fills us 
with amazement. (quoted in Caton 1999, 93)

The Problem of Pain
Physical pain produces neural responses that sort into different components 
(Price 2000). First is the sensory experience itself. Parts of somatosensory 



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cortex and sensory relays of the thalamus mediate the sensory aspects of pain. 
Second is the subjective sense of “unpleasantness,” which is mediated by the 
insula and the anterior cingulate. The insula controls our autonomic nervous 
system. The anterior cingulate integrates attentional and cognitive experienc-
es of pain with their emotional valence and establishes priorities for possible 
responses. Finally, pain produces emotional feelings directed at the long-term 
implications of having pain. The amygdala, anterior cingulate, insula, and 
prefrontal cortex are all part of the distributed network that mediates emo-
tional distress and its interactions with our cognitive systems, providing the 
neural underpinning where physical and emotional pain converge.

As the understanding of the neurobiology of emotional systems deepens, 
treatment of psychological pain becomes more easily viewed as a mechanical 
rather than a metaphysical manipulation. Similarly, it is hard not to see such 
intervention in humanitarian terms. Some estimate that up to a quarter of 
the U.S. population suffer from affective or addictive disorders (Kessler et al. 
2005). how could anybody seriously object to the alleviation of this suffer-
ing, even if it means that some might pop pills for less compelling reasons?

The fundamental problem in using first principles to establish a coherent 
position on ameliorating psychological pain is that any general unease around 
widespread treatment of pain does not cohere when specific instances are 
considered. At issue is whether we view pain as important to living a good life 
or whether we frame pain as an impediment to living a good life. Attitudes 
towards psychological pain and its treatment fragment into competing and 
conflicting frames that are held simultaneously (Chatterjee 2008; see Parens 
2005 for a similar discussion about ambivalences around enhancement and 
authenticity). We can worry about loss of character individually and commu-
nally, yet at the same time we frame psychological pain in biological or broad 
humanitarian terms. We might share the general sense that some things are 
best left alone, but we are unlikely to agree about which specific things are 
best left alone. We might share the view that pain serves a purpose in estab-
lishing order, but we are unlikely to concur which pains can be justified and 
for whose version of order. We might share the general sense that pain can 
be a vehicle for development, but we are unlikely to share opinions of which 
specific pains are worth enduring for which specific gains.

Pill-popping Professors
What about academics using brain boosters? While there was relatively little 
new information in the article in Nature, it attracted considerable attention. 
Perhaps this attention was fueled by the fact that the practice was not about 



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“those people” (athletes, students, soldiers), but about us—academics. Profes-
sional narcissism aside, how might we view the possibility that the practice of 
academics taking cognitive enhancers could become widespread? Analogous 
to the way that treatment of pain can be viewed as important to living a good 
life or not, enhancing professors can be viewed as important to constructing 
a good society or not. As in the case of psychological pain, the evaluation of 
the practice of cosmetic neurology depends on which frame of reference is 
brought to bear on this question. here, a “greater good” frame conflicts with 
a “fairness in competition” frame.

The greater good frame is as follows. Some workers have a disproportionate 
impact on the greater good of our society. Their functioning well bears directly 
on societal health and protection. It is no surprise that considerable research 
and use of cognitive enhancers occur in the armed forces. There is little public 
outrage at this practice. The logic is that our military serves a vital public role, 
and it is in our interest that military personnel perform at their peak.

A variant of this greater good frame is a revelatory one. On this view, cog-
nitive enhancers clear the way for one’s natural talents to be revealed. The 
prime example of a practice framed this way is the widespread use of beta-
blockers by musicians to dampen tremors and reduce performance anxiety. 
Again, there is little public outrage at this practice. A line seems to be drawn 
between the intrinsic talent to perform music and the ways this talent could 
be hampered by the performer’s messy affective state.

The fairness in competition frame is as follows. We want a level playing 
field so that, when individuals compete with each other, we observe their 
intrinsic talents on display, the consequences of their hard work and disci-
pline, such that the best person wins. This sensibility pervades the public view 
of sport. Consequently, there is considerable public outcry at each story of 
baseball players or track athletes taking anabolic steroids or amphetamines 
to enhance their performance. here the enhancers are seen as compromising 
something essential to the performance. The sense of fair play, intrinsic to 
the joy of competition, is violated. And individual achievement, which we 
admire, is sullied.

how do these reference frames, admittedly drawn coarsely, map onto 
academia? The greater good frame seems obvious. Academics are in the busi-
ness of uncovering new knowledge, making discoveries and generally enhanc-
ing the quality of our lives. The public would want academics at the peak of 
their potential, because their product serves a greater good. The revelatory 
variation might also apply to academics. talented academics have a gift. They 
serve as vehicles for discovery, insight, and creativity—and the medications 



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used to facilitate the delivery of these gifts are desirable. On these grounds, 
one might think there is no problem with academics using enhancers. Pill-
popping professors would be desirable insofar as they more effectively con-
tribute to the construction of a good society.

The fairness frame also applies to academics. One might imagine academ-
ics as pure altruists dedicated to the sole purpose of advancing knowledge. 
On this view, no such thing as professional rivalry would exist. Academics 
would not compete with each other, and everybody would co-operate in the 
grand program of advancing society. Would that it were so. Academics, like 
others, compete for professional promotions and accolades, wish to be first 
in their discoveries, and hustle in the marketplace of ideas. We are subject to 
winner-take-all environments in which incremental advantages can result in 
disproportionate rewards. These competitive aspects of academia are on the 
rise. In academic medicine, “publish or perish” seems a quaint anachronism 
of a kinder and gentler time. “Cash or crash” seems more appropriate as 
many tenured academics in medicine lack guaranteed salaries and are only 
as valuable as their last grant. Medicine might seem more like a dingy dun-
geon than an ivory tower, but these financial pressures on medical academics 
arose out of desires to contain medical costs. Given the continuously rising 
cost of higher education, similar pressures might also apply to other aca-
demic settings. In this frame, the use of cognitive enhancers is problematic 
on two grounds: first, it violates our notions of fairness; and, second, as com-
petition rises, it could be deeply coercive. Pill-popping professors reify the  
uglier aspects of competition. By endorsing a system in which the benefits of 
“progress” outweigh almost any cost, they contribute to the breakdown of a 
good society.

In summary, the Nature article alludes to a trend in the use of cognitive 
enhancers among academics that, in my view, is likely to continue. This use 
is yet another example, albeit closer to home for those reading this journal, of 
the increasing practice of cosmetic neurology. Whether one views this prac-
tice with anticipation or with alarm depends on which conflicting reference 
frame one brings to bear upon the issue.

Acknowledgment

I would like to thank Lisa Santer, Erik Parens and Barry Schwartz for their 
helpful comments and critical insights that enhanced this piece, hopefully for 
the greater good.



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