PERIPHERALIA

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Over the last few years I have had a small but steady 
number of normal students asking for stimulants such as 
methylphenidate (Ritalin, Concerta) to help them with their 
studying and exams. This may partly be because my rooms 
are near our local university campus.

Methylphenidate (Ritalin) was launched onto the market 
in 1955 and almost every year since there has been an 
alarmist article in the Sunday Times on the negative aspects 
or reactions to this drug. Myths seem to have attached 
themselves to these stimulants mostly on the themes of 
“controlling or altering the mind”. If one considers that 
there are 2 million prescriptions written per month for 
Methylphenidate in the USA alone, one is going to get some 
stories that circulate around the morning coffee tables. It is 
interesting to note that until recently it had no street value 
and was not a drug of abuse, but now with the fashion of 
snorting almost everything under the kitchen sink, it has 
been pulled into the mixtures.

In recent years, stimulant medications have increasingly 
been prescribed and used to improve academic performance 
in normal students (called cognitive enhancement). This 
raises several ethical questions. Is it fair if the schoolboy 
or girl on methylphenidate wins the Maths prize? Should 
the university student on methylphenidate who gets 
distinctions be awarded the bursary? Should the manager on 
methylphenidate or other prescribed stimulants who finishes 
his project fastest and in the most detail get the promotion? 

In addition, under the ethic of distributive justice only a small 
percentage of the students are able to afford these expensive 
drugs, so this is discriminatory on the basis of economic 
inequality. 

There are other ethical issues. Methylphenidate is licensed 
to be prescribed for ADHD and narcolepsy. Prescribing 
it to improve academic performance in a normal 
subject is prescribing the drug “off-label” and not in the 
recommendations of the producers. We are into unknown 
territory here firstly because we are giving it to normal 
healthy subjects. It is one thing to prescribe a medication 
for an illness but other issues arise when giving it to normal 
bystanders. One runs the risk of giving side effects to healthy 
people. The “off-label” nature of the prescription and the 
potential harms (material risks) have to be explained to 
individual clients (they are not patients in a true sense) as 
well as the alternatives available. 

Another question that arises is, do these stimulants actually 
work and improve thinking, memory, and academic 
performance? The evidence of efficacy is not conclusive. One 
needs to do a comparison with a placebo, a double expresso 
or some Red Bull. The effects may only be due to the general 

alertness, wakefulness and energy of the stimulant that 
allows one to concentrate and study.

Let us take a group of “normal” non-incendiary students. 
How do you actually chose them for a trial? Firstly, there are 
the baselines of cognitive functioning. There are the low 
performers, Mr Average in the middle, and the high flyers. 

You would think that if you gave stimulants to the high flyers 
in the class you could improve them into Supergalactic Flyers 
but this is not necessarily the case; there appears to be an 
optimum limit and then their performances may actually 
deteriorate. 

One of the great problems of doing research in this area of 
human cognition is the problem of the variability in response 
across and within individuals. If you do manage to find a 
“normal” group to do research on, some may not respond 
at all or very little while others may greatly benefit from the 
intervention. Will the low academic performers benefit the 
most, or will specific areas be improved while others are not 
improved or compromised? There may also be, in the normal 
group, subjects with undiagnosed ADHD or subgroups with 
specific genetic predispositions that react in positive or 
negative ways to the drugs. 

The use of enhancements has been around for a longtime. 
Performance in sport with steroids, enhancement of physical 
features with cosmetics, and improvement of sexual function 
are all aimed at improving on “the normal”. 

We are now into an era of “improving on nature” and making 
people better than well. It is the 21st century of Superman 
and Superwoman. This is now referred to as the Post-Human 
State.

Pharmaceutical cognitive enhancements (known as 
academic steroids or study drugs) are a recent unknown field 
of endeavour, which will raise complex ethical and moral 
dilemmas. Conservatives caution that it will undermine the 
value of human effort while others argue for its promotion to 
maximize human potential.

I envisage the mother of the future sending her child off to 
school and saying “here is your concentration pill and here 
is your memory pill, and don’t forget your calculating pill for 
Maths.” “Oh, and here are your vitamins.” “Now remember to 
switch on the microchip that we had implanted in your brain 
last year.”

I hope she does not forget the child’s lunch. 

Chris Ellis is a family physician from Pietermaritzburg, 
KwaZulu-Natal

Email: cristobalellis@gmail.com

Ethical issues with cognitive enhancement