Tuesday, May 15, 2018

Regulating Minds: A Conceptual Typology

By Michael N. Tennison 

Image courtesy of Wikimedia Commons.
Bioethicists and neuroethicists distinguish therapy from enhancement to differentiate the clusters of ethical issues that arise based on the way a drug or device is used. Taking a stimulant to treat a diagnosed condition, such as ADHD, raises different and perhaps fewer ethical issues than taking it to perform better on a test. Using a drug or device to enhance performance—whether in the workplace, the classroom, the football field, or the battlefield—grants the user a positional advantage over one’s competitors. Positional enhancement raises issues of fairness, equality, autonomy, safety, and authenticity in ways that do not arise in therapy; accordingly, distinguishing enhancement from therapy makes sense as a heuristic to flag these ethical issues. 

These categories, however, do not capture the entire scope of the reasons for and contexts in which people use drugs or devices to modify their experiences. Consider psychedelic drugs like psilocybin and LSD that induce mystical-type experiences. Studies show that these drugs also have the potential to treat depression, anxiety, and addiction. They can even lead to positive changes in the personalities and behaviors of healthy subjects, such as increased openness and altruism, that can persist long-term without retaking the drug—effects that are neither therapeutic in the sense of treating a diagnosable condition, nor are they positional enhancements akin to taking steroids to gain a leg up on one’s athletic competition. 

Legal regimes that regulate drugs in the United States present a different dichotomy for distinguishing uses of drugs, ostensibly based on their risk/benefit ratios. In general, FDA laws and regulations authorize the therapeutic use of drugs proven to be sufficiently safe and effective, and controlled substance laws criminalize the use of drugs determined to lack medical value or that are obtained and used outside the scope of medical treatment. Unfortunately, the “War on Drugs”—the laws and policies implementing controlled substance restrictions—produces myriad side effects. These include unintuitive, unscientific, and politically-motivated drug classifications, interference with medical research, misinformation about the risks and benefits of drugs, stigmatization of non-problematic drug use, and the privileging of medical value as the only redeeming benefit an illegal drug can have, not to mention the panoply of harms imposed by criminalization. 

In a step toward developing a robust assessment of drug harms, a UK study ranked drugs based on their harm to users and others, using physical, psychological, and social criteria.  The findings, later endorsed by a panel of experts from across the EU, suggest a mismatch between the legal treatment of drugs and their comparative harms.  
Although ensuring the safety and effectiveness of drugs is an absolutely essential government function, generalizing and criminalizing non-medical use as “recreational drug use” or “drug abuse” fails to account for, and stifles, the other ways drugs can and do benefit individuals and society. Again, consider psilocybin, a drug designated in the United States as having no accepted medical value, a high potential for abuse, and no capacity to be used safely under medical supervision—a stricter legal classification than for cocaine, methamphetamine, and fentanyl. Even if conclusively proven safe and effective for medical or enhancement purposes, it would still be illegal to obtain and use psilocybin to enhance insight, catalyze personal development, and cultivate altruism and openness. Short of congressional action, there is no legal mechanism to acknowledge the scientific evidence of a scheduled drug’s safety and effectiveness for enhancement, and therefore authorize its non-medical use. 

The legal classification scheme fails, therefore, to accurately represent and respond to rapidly-accumulating, novel evidence about the actual risk/benefit ratios of certain drugs like psilocybin, while the neuroethical enhancement/therapy paradigm fails to account for the uses of drugs and devices that fall outside the boundaries of medicine and positional enhancement. I propose creating a single framework of functional categories that serves as both a descriptive typology and a normative spectrum that balances a higher level of precision and accuracy with the categorical bundling of thematic clusters of ethical issues. Ordered from the most to least ethically-justified, based on risk/benefit ratios at individual and collective levels, this framework comprises therapy, virtue enhancement, utility enhancement, and recreation enhancement. 

Therapy 

Therapy aims to restore the health and “normal” functions of individuals impaired by disease or injury. In discussions about enhancement, therapy tends to be the normative baseline against which enhancement is compared and contrasted because, over time, we have accrued a set of familiar attitudes, norms, and legal structures that drive our understanding of medical treatment. We understand that health and healthcare are prerequisites to flourishing as individuals and societies. 

Virtue Enhancement 

Image courtesy of Flickr.
Studies show that the controlled and supervised administration of psychedelics reliably induces a “peak” or “mystical” subjective experience of altered perceptions, mood, and cognition characterized by feelings of oneness, transcendence, and ineffability. Anxiety and fear are not uncommon elements, but careful management of the “set and setting” of the experience successfully protects the psychological safety of study participants. In a 2006 study, most subjects rated their psilocybin experience as “either the single most meaningful experience of his or her life or among the top five most meaningful experiences of his or her life.” Further research recently demonstrated that this may lead to sustained, positive changes in personality, worldview, or behavior that may benefit society, especially if reinforced by personal development practices such as meditation. 

I differentiate virtue enhancement from the kind of “moral enhancement” envisioned by bioethicists that would neurologically force the expression of a pro-social behavior, such as honesty, and that would only be effective so long as the individual is under the enhancement’s neurochemical influence. By contrast, studies show that psychedelic experiences may prompt a more “natural” or authentic pursuit of personal development that persists long after the drug experience itself has passed

Utility Enhancement 

This category refers to the use of a drug or device to enhance performance in an outcome-based endeavor. Whereas virtue enhancement is valuable in itself and in consequence for individuals and society, utility enhancement is valuable primarily in consequence. And despite enhancing performance on collectively-valued activities, such as work, academics, and sports, the overall value of utility enhancement is limited by the myriad of ethical issues raised. 

Utility enhancements are typically positional enhancements that grant leverage in zero-sum endeavors where people are competing for limited resources. For example, it is generally considered unfair for an athlete to use steroids to enhance performance in sports, because a better outcome for the enhanced individual or team automatically means a worse outcome for the opponent. Additionally, players may not have equal or affordable access to the most effective, least detectable, and safest enhancements, and many athletes may not want to risk professional or legal penalties if they are caught. Yet to remain competitive, they may feel forced to enhance themselves, thereby reducing their freedom and autonomy. 

Recreation Enhancement 

Image courtesy of Pxhere.
On one hand, recreation enhancement entails the use of a drug or device to enhance one’s experience of a recreational activity. Using a transcranial stimulation device to enhance video game performance, for example, provides some individual benefit without raising substantial ethical issues at the collective level. Studies now show that psychedelics can enhance the emotional appreciation of music, a finding that spans recreation, virtue enhancement, and even therapy—depending on the context and intent of use—and could have both individual and collective benefit. 

On the other hand, people also modify their minds with drugs and devices as a form of recreation itself. This parallels the concepts of “recreational drug use” and Robert Nozick’s “experience machine”—a critique of hedonism—entailing escapism or “tuning out” from reality. By chemically or electrically inducing a desired state, such as satisfaction or pleasure, one circumvents the natural process of effort and achievement, raising concerns about authenticity and the prospect of an unfavorable ratio between benefits and health risks. If a user seeks a change in consciousness as a short-term end goal in itself, without harnessing it to pursue other ethically-sound ends, it may provide little overall benefit to the individual or society. However, it is not necessarily harmful if not pursued to the point of interference with health or responsibilities. 

None of the above categories should be conflated with use disorders. In fact, a use disorder could result from the inappropriate pursuit of any of the above categories of substance use. According to SAMHSA, the DSM-5 defines a substance use disorder as being present when “the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.” Despite the prevalence of use disorders revealed by the nation-wide opioid crisis in the United States, it is important to remember that 80-90% of users of illegal drugs do not have a drug problem, according to Dr. Carl Hart, neuroscientist and chair of psychology at Columbia University. Similarly, data from a 2017 report of the UN Office on Drugs and Crime show that globally, almost 90% of people who use internationally-controlled drugs do not have substance use disorders. Indeed, by taking seriously the studies that demonstrate the non-problematic and even beneficial uses of drugs legally-classified as necessarily harmful, we are better equipped to identify risk factors of addiction and problematic use. 

Laws should encourage activities that benefit individuals and society and discourage those that do not. Creating a unified and coherent approach to understanding how and why people manipulate their consciousness with drugs and devices is a first step toward systematically incorporating intuitive, evidence-based risk/benefit analyses into our ethical, legal, social, and policy discussions. This facilitates the accurate identification and assessment of the unique clusters of ethical issues associated with different purposes and outcomes of drug and device use. Such assessments could be translated into laws and regulations that promote the discovery and application of beneficial manipulations of consciousness, even if non-medical, while implementing structures and processes to reduce their risk of harm. The next steps entail sorting out how drugs and devices could be approved and administered for different kinds of enhancement, including the requisite thresholds of scientific proof of safety and effectiveness and the proper context of use to minimize risks—whether inpatient, over the counter, by prescription, or after demonstrating sufficient knowledge and competence, as with obtaining a driver’s license. A model like the one proposed above can enhance our neuroethical analyses and help us to overcome our dangerous experimentation with harmful drug laws and policies.
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Michael N. Tennison is a Senior Law & Policy Analyst at the University of Maryland Center for Health and Homeland Security. His research interests focus on the ethical, legal, social, and scientific issues associated with drug policy. The opinions expressed are the author's own and do not represent the view of the Center for Health and Homeland Security or the University of Maryland. Portions of this post are adapted from the author’s poster presentation at the 2017 Annual Meeting of the International Neuroethics Society


Want to cite this post?

Tennison, M. (2018). Regulating Minds: A Conceptual Typology. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2018/05/regulating-minds-conceptual-typology.html

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