Jessica Flanigan, Adderall for All: A Defense of Pediatric Neuroenhancement, 25 HEC Forum 325 (2013)
Abstract
I argue that young patients should be able to access neuroenhancing drugs without a diagnosis of ADHD. The current framework of consent for pediatric patients can be adapted to accommodate neuroenhancement. After a brief overview of pediatric neuroenhancement, I develop three arguments in favor of greater acceptance of neuroenhancement for young patients. First, ADHD is not relevantly different from other disadvantages that could be treated with stimulant medication. Second, establishing a legitimate framework for pediatric neuroenhancement would mitigate the bad effects of diversion and improve research on neuroenhancement and ADHD. Third, some pediatric patients have rights to access neuroenhancements. I then consider several objections to pediatric neuroenhancement. I address concerns about addiction, advertising, authentic development, the parent–child relationship and equal opportunity and conclude that these concerns may inform a framework for prescribing neuroenhancement but they do not justify limits on prescribing.
Introduction
Pediatric neuroenhancement refers to the practice of prescribing stimulant medication to enhance concentration and potentially boost academic performance in children and adolescents who do not suffer from behavioral or psychiatric disorders. The practice has been the subject of growing popular and academic attention. Nonmedical use of neuroenhancement among teenagers and children is on the rise, as is scrutiny of the practice. In this essay, I defend pediatric neuroenhancement for healthy children and teenagers, and I argue that non-medical conditions should be recognized as legitimate reasons for medical treatment, including prescription drug use.
My central claim is that pediatric patients should be able to access neuroenhancing drugs without a diagnosis of attention deficit hyperactivity disorder (ADHD). The current framework of consent for pediatric patients should be adapted to accommodate neuroenhancement. In some cases, pediatricians should be empowered to recommend and provide stimulants to school-aged patients without ADHD if the patients assent to treatment and their parents give informed permission. Depending on adolescents’ level of medical competence, they are either entitled to unrestricted access to neuroenhancing drugs or to pediatricians who may permissibly prescribe neuroenhancements without parental permission if the patient gives informed consent. Providing children with stimulants as neuroenhancements is not only permissible, doing so may at times be morally praiseworthy.
After a brief overview of pediatric neuroenhancement, I develop three arguments in favor of greater acceptance of neuroenhancement for young patients. First, ADHD is not relevantly different from other disadvantages that could be treated with stimulant medication. Second, establishing a legitimate framework for pediatric neuroenhancement would mitigate the bad effects of diversion and improve research on neuroenhancement and ADHD. Third, autonomous pediatric patients, (e.g., teenagers), have rights to access neuroenhancements. I then consider several objections to pediatric neuroenhancement. I address concerns about addiction, advertising, authentic development, the parent–child relationship, and equal opportunity, and conclude that these concerns may inform a framework for prescribing neuroenhancement but do not justify regulations or limits on prescribing.
Background
Stimulants like Ritalin (methylphenidate) and Adderall (mixed amphetamine salts) are marketed and prescribed for the treatment of ADHD because they enable patients to concentrate, listen and retain information, control impulses, and regulate their emotions. Stimulant use can also improve academic performance and enable patients to more easily form and maintain friendships while mitigating the risks of depression or aggressive behavior for patients with ADHD. School-aged children and young adults are increasingly being diagnosed with the disorder. As of 2007, *9.5 % of children ages 4–17 have been diagnosed with ADHD (CDC—ADHD, Data and Statistics 2013). The rise in diagnoses has been accompanied by a rise in medication, especially in the United States.1
Along with the rise in children with ADHD diagnoses who use medication for it, non-medical stimulant use is also on the rise. Surveys reveal that 4.5 % of middle and high school students have used stimulants without a prescription (McCabe et al. 2004).2 Adolescents without a prescription obtain the drugs from their peers, who either sell or give them prescription medication. Drug diversion is illegal—some stimulants such as Adderall—are classified by the Drug Enforcement Administration (DEA) as schedule II substances when used without a prescription. Non- medical adult users can be convicted of felony drug abuse and punished with jail time for using ADHD drugs. Diversion also means that patients with prescriptions for ADHD treatment misuse their drugs by selling or giving away some of the recommended dosages.
An increasing number of diagnoses of ADHD may also mask the prevalence of non-medical stimulant use. Dr. Michael Anderson, a pediatrician who treats low- income families near Atlanta, was featured in the New York Times as a physician who provides ADHD medication to children who may not have the disorder so that his patients can succeed in underfunded and overcrowded low-income public schools (Schwarz 2012). Anderson defends this practice, arguing ‘‘I don’t have a whole lot of choice...We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.’’ Anderson’s report of his prescribing practices, and others like his, may explain recent charges of overdiagnosis of ADHD. A recent study of ADHD prevalence among a sample of 10,427 children found that only 28.3–39.5 % of children who were medicated for ADHD met the diagnostic criteria for the disorder (CDC—ADHD, PLAY Study Findings 2012).
The trend toward pediatric neuroenhancement has only recently received scholarly attention. Most analyses of neuroenhancement have focused on whether stimulants actually do provide clear benefits from patients without ADHD. The prevalence of illicit use and anecdotal evidence suggests that it does (Anonymous 2009a; Greely et al. 2008). There is also some evidence that stimulants for healthy adults brings modest gains in memory and may improve some elements of executive functioning (Repantis et al. 2010). Almost two-thirds of studies of stimulant use have found an effect on cognitive processes of healthy adults, although some studies also report cognitive impairments for some users (Smith and Farah 2011).
In addition to the cognitive effects there are also emotional benefits associated with neuroenhancement such as enjoyment of work, a sense of interestedness, energy, drive, and general well-being (Vrecko 2013). Scott Vrecko reports that users sometimes acknowledged that stimulants did not improve their cognitive abilities but that they believed the drugs to be beneficial because of the emotional and behavioral effects (Vrecko 2013). Pharmaceutical neuroenhancement may benefit patients purely through a placebo effect, or by increasing perceived gains in performance (Hall and Lucke 2010). Yet, even a placebo effect could have beneficial consequences by boosting confidence or alleviating anxiety.
On the other hand, most scholars who study neuroenhancement caution against overstating the benefits, pointing out that neuroenhancement does not typically improve grades or learning in healthy subjects, or even in patients with ADHD, and that the gains in memory are limited (Advokat and Vinci 2012; Lucke et al. 2011). One problem with assessing the benefits of neuroenhancement is that it is difficult to support a clinical trial for treatment of healthy adults, so there are not many good randomized studies of the effects of neuroenhancement. It is also difficult to assess baseline performance when testing neuroenhancement (Repantis et al. 2010). Some scholars have turned to epidemiological evidence to assess the risks and benefits of neuroenhancement, but in these cases it is difficult to establish whether pharmaceutical use or other factors (e.g., selection effects) explain differences in performance between healthy stimulant users and nonusers. Another difficulty with assessing the benefits of enhancement is that individual differences in response to enhancements have led to null results when some users in fact benefited (Smith and Farah 2011, p. 19).
The scientific controversy surrounding neuroenhancement is mirrored in discussions of the ethics of neuroenhancement for adult patients (Brukamp and Gross 2012; Brukamp 2013). In a 2008 commentary published in Nature, seven prominent health care scholars argued that pharmaceutical neuroenhancements, and information about neuroenhancements, should be more accessible (Greely et al. 2008).3 The Ethics, Law, and Humanities Committee of the American Academy of Neurology advises that it is permissible for physicians to provide adult patients with such pharmaceuticals but that physicians are not required to do so (Larriviere et al. 2009). Several bioethicists also support adult neuroenhancement (Dees 2007; Savulescu 2011). On the other hand, the Society for the Study of Addiction states that any guidelines are premature because there is not sufficient evidence to justify legitimating the practice (Lucke et al. 2011). Some bioethicists agree and point out that the benefits of neuroenhancement are unclear and that the potential for addiction and negative social consequences should not be understated (Heinz et al. 2012).
The uncertain scientific evidence on neuroenhancement inspires even more caution when children and adolescents are involved, especially because evidence of efficacy is exceptionally scarce for pediatric neuroenhancements. And evidence is not likely forthcoming because tests that subject healthy children to risky pharmaceuticals with no established medical benefit are unlikely to be deemed ethical.4 Citing this lack of evidence, the American Academy of Neurology, Child Neurology Society, and American Neurological Association conclude that ‘‘neuroenhancement in legally and developmentally non-autonomous children and adolescents without a diagnosis of a neurologic disorder is not justifiable’’ (Graf et al. 2013). The authors of the paper allow that their recommendation against pediatric neuroenhancement is weaker for nearly autonomous adolescents but maintain that the prescription of neuroenhancements even for teenagers is inadvisable because enhancements could potentially hinder authentic development. Another concern that motivates the Academy’s recommendation against neuroenhancement is the worry that a fair distribution of neuroenhancing drugs would be difficult to achieve and contentious.
These challenges associated with translating the ethics of adult neuroenhancement to the pediatric case led Singh and Kelleher to develop a framework for ethical pediatric use that builds on the existing framework for pediatric ADHD treatment (Singh and Kelleher 2010). They argue that pediatricians should recognize neuroenhancement as a legitimate reason for stimulant use and develop a framework for ethical prescribing, mainly because the practice is becoming more prevalent and further increases are seemingly inevitable. Singh and Kelleher’s recommendations are limited to occasional stimulant use. Like the Academy of Neurology, Singh and Kelleher caution against daily long-term stimulant use because they judge that the risks cannot justify the potential benefits of neuroenhancement. Yet as critics have noted, Singh and Kelleher assume that legitimizing pediatric neuroenhancement is appropriate given its current prevalence, but the fact that a practice is widespread does not mean that it ought to be or that medical professionals should recognize it (de Melo-Mart ́ın 2010). A further argument that neuroenhancement is appropriate is needed to justify Singh and Kelleher’s recommendations.
Disability and Disadvantage
Though Singh and Kelleher do not provide a detailed argument for the appropriateness of pediatric neuroenhancement, several arguments can be given in favor of legitimating the practice. First, the same considerations that justify the prescription of stimulants for ADHD also justify the prescription of stimulants for other forms of disadvantage. Medical professionals should treat the whole patient, meaning that treatment should account for a patient’s overall well-being and values and not just her health. Medical conditions like ADHD are not the only detriments to overall well-being that can be treated with medical solutions. Since neuroenhancement should be understood as a legitimate purpose of medicine, the current standards of consent to medical treatment, as they apply to patients with ADHD, for example, should also apply to neuroenhancement (Subcommittee on Attention-Deficit/Hyperactivity Disorder 2011). This means that pediatricians, parents, and patients should decide together if neuroenhancement is an advisable choice. Just as public officials are not well-suited to make judgments about the appropriateness of prescribing stimulants for the treatment of ADHD in particular cases, neither are they well-suited to make judgments about particular cases of neuroenhancement.
Begin with the premise that the prescription of stimulants for the treatment of ADHD is justified. If ADHD is not relevantly different from other forms of disadvantage that can be alleviated by stimulant use, then insofar as stimulant use can correct for a disadvantage that is relevantly similar to ADHD in its effects on a patient’s overall well-being, stimulant use to that end should be permitted as well. Now consider two cases of pediatric methylphenidate use to illustrate the current controversy surrounding pediatric neuroenhancement:
ADHD Sasha is a 10-year-old who has been diagnosed with ADHD. Although Sasha attends a nationally recognized private school, has two attentive and informed parents, access to private tutoring, and an individualized education program, she is struggling and falling behind academically because of her disability. Sasha’s pediatrician recommends Ritalin as a way of managing Sasha’s symptoms. The family is educated about the risks and benefits of treatment. Sasha gives her assent and Sasha’s parents give permission for Sasha to use Ritalin. Once Sasha starts using Ritalin her grades improve and Sasha finds school more enjoyable and less stressful.
Neuroenhancement Tim is struggling in school. His school is understaffed and overcrowded and his classroom is full of distractions and loud noises that make it difficult for Tim to effectively focus and learn in the classroom. Tim struggles with homework, but his parents are overwhelmed with work and caring for Tim’s other siblings and they cannot afford a tutor to help him complete each assignment. Tim does not have ADHD, but his pediatrician recommends Ritalin as a way of managing his difficult academic circum- stances. The family is educated about the risks and benefits of treatment. Tim gives his assent and Tim’s parents give permission for Tim to use Ritalin. Once Tim starts using Ritalin his grades improve and he finds school more enjoyable and less stressful.
In both cases, Sasha and Tim are disadvantaged in ways that affect their academic performance. Sasha’s disadvantage is ADHD, a medical condition that is widely treated with Ritalin. Tim faces nonmedical disadvantages, but a medical solution like Ritalin may still be effective. The prescription of Ritalin for nonmedical disadvantages is discouraged, however, even if treatment is effective in both cases and even if patients like Tim struggle more on average than patients like Sasha.
This asymmetry in how the two cases are treated is a mistake. Children with ADHD are appropriately prescribed stimulants because having ADHD is a disability. Yet underlying this practice is a particular conception of disability: that treatment is appropriate for conditions that adversely affect the patient’s performance in circumstances where the quality of one’s performance is especially important. For children with ADHD, the relevant circumstance is their educational environment. ADHD is primarily diagnosed through teachers, and a patient’s symptoms may not present outside the classroom (Mayes et al. 2008). To obtain a medication, teachers may even be required to participate in making a diagnosis of ADHD by submitting reports of classroom performance to a pediatrician. In other circumstances, like creative contexts, ADHD may even be an advantage (White and Shah 2011). This suggests that ADHD is not intrinsically disabling but only disabling in the classroom context. For these reasons, ADHD treatment is often best understood as an academic enhancement, or at least as a corrective for an academic deficit, because it primarily aims to bring academic benefits.
There are other reasons that a child’s particular educational circumstances could cause serious difficulties and hinder learning and academic achievement. For patients like Tim, ADHD does not explain classroom difficulties; failing schools are the reason that Tim is disadvantaged. Just as ADHD is a disability because it impairs children’s ability to succeed in the school environment, a distracting and understaffed environment can be similarly disabling.
ADHD does have a stronger biological basis than failing schools, but this consideration does not necessarily support limiting access to stimulant medication only for students with ADHD. Traditional lines between medical and nonmedical conditions and between treatment and enhancement are difficult to sustain. There is not a definitive biological test for ADHD and its prevalence is influenced by a person’s home and learning environment (Hart et al. 2010). In any case, pediatricians should not narrowly concern themselves with identifying and treating a particular biological condition but instead should focus on the patient as a whole. If a patient could benefit on balance from stimulant use then a pediatric patient ought to be provided access. In some cases, stimulants may be inappropriate for certain patients with ADHD because of severe side effects and appropriate for certain patients without ADHD because they suffer from failing schools or other circumstances that constitute a significant disadvantage. However, the decision to prescribe stimulants should not be informed by asking, ‘‘Can this medication treat a particular medical condition?’’ but rather, ‘‘Can medication make the patient’s life better on balance?’’ The answer will be no for some patients with ADHD and yes for others.
Critics of pediatric neuroenhancement will point to the lack of evidence about the efficacy of stimulants and safety concerns about extended use. First, consider concerns about safety. Although the safety of stimulants for neuroenhancement has not been extensively studied, the safety of pediatric stimulant use is well understood for patients with ADHD and few adverse effects are reported (Repantis et al. 2010, p. 203).5 More generally, safety is a normative judgment, not a scientific judgment. Of course, evidence about the risks and side effects is relevant to a judgment of safety, as is knowledge about what is unknown, but ultimately the judgment of whether a drug is ‘‘acceptably safe’’ rests on a judgment of whether the risks are justified in light of the potential benefits to the patient’s overall expected well-being with medication.
Patients with and without ADHD vary. For some children with ADHD the risks might not justify the benefits and it may be inappropriate for a pediatrician to prescribe stimulants. For example, if a patient has ADHD but does not suffer severe adverse academic or social effects her pediatrician may judge that treatment is unwarranted. Similarly, children without ADHD may justifiably be exposed to the known and unknown risks of neuroenhancement, if they face significant disadvantages that could be treated with medication.
Skepticism about the efficacy of neuroenhancers may also undermine support for legitimating pediatric neuroenhancement. Unlike safety, efficacy is not necessarily based on a normative judgment. Health professionals and patients should deem a drug effective on the basis of whether the patient experiences relief of her symptoms after using the drug.6 A clear lack of evidence that neuroenhancers were effective could therefore undermine the case for pediatric neuroenhancement because the drugs do carry some risks. However, the limited available experimental evidence suggests that there are some benefits to neuroenhancement. Further evidence of an effect can be found in the increasing numbers of middle and high schoolers who illegally access neuroenhancements for academic benefits. Anecdotal evidence also indicates that at least some patients benefit from neuroenhancement. These benefits have lead some pediatricians to diagnose children like Tim with ADHD so that they may access stimulants as a way of overcoming failing schools and a lack of academic support (Schwarz 2012).
For school-aged children, concerns about the risks and benefits of medication are legitimate considerations for a pediatrician to consider because pediatricians assume at least some responsibility for their patients’ well-being, along with parents and the patients themselves. But these concerns should be assessed at the level of overall benefits and risks to the child, not exclusively medical risks. If a pediatrician anticipates that medication could benefit a healthy child on the whole she could permissibly prescribe neuroenhancements. Because the potential benefits are unclear for each individual patient, with or without ADHD, pediatricians are encouraged to monitor patients for side effects and signs of improvement.7 If prescribing neuroenhancers does not clearly benefit the child, pediatricians should be permitted to discontinue the practice. An alleged lack of benefit for most healthy patients does not justify a blanket recommendation against pediatric neuroenhancement, however, because some healthy patients may benefit and those who do not can simply discontinue treatment.
These considerations call for a slight but significant revision of the current approach to prescribing stimulants in young patients. Existing standards of pediatric consent can be adapted to accommodate neuroenhancement. Pediatricians may remain the gatekeepers to pharmaceuticals for young patients, but should be open to considering all kinds of young patients as candidates for prescriptions. As in the case of adult neuroenhancement, physicians are not obligated to provide enhancements if they have conscientious objections to the practice or if they judge that medication is unacceptably risky (Larriviere et al. 2009).
On the other hand, it is also morally praiseworthy for parents and physicians to choose to make existing children’s lives as good as they can be. This is not to say that parents and pediatricians are morally required to provide neuroenhancements when they suspect that the drugs would be beneficial, but that it is beneficent to give children greater opportunities and to correct for existing disadvantages. Parents and pediatricians have rights to refuse to act beneficently just as parents have rights to choose sub-optimal educational plans or to refuse to pay for tutors even if they have the resources to provide better opportunities, but parents who choose the best schools and tutors are especially praiseworthy for doing so.
The Dangers of Limits on Access
Establishing a framework for pediatric neuroenhancement will also enable further investigation into the risks and benefits of non-medical stimulant use. Critics of pediatric neuroenhancement have emphasized the dangers of providing medication to healthy children, but overlooked the dangers of denying healthy patients a legitimate path to access for neuroenhancement. Legitimizing pediatric neuroenhancement will also enable researchers to better understand ADHD by discouraging the current trends toward over diagnosing ADHD. In addition, recognizing neuroenhancement as a legitimate reason for stimulant use could encourage illicit stimulant users to seek medication through safer channels. Given the current prevalence of a black market for neuroenhancers among middle and high school students, there is reason to suspect that a path to access for non-medical users that includes monitoring and patient education could have some public health benefits over the current system.
Illicit neuroenhancement is not uncommon among school age children (McCabe et al. 2004). The pervasiveness of the illegal stimulant use is seemingly Singh and Kelleher’s main motivation for arguing in favor of allowing pediatric neuroenhancement more explicitly. Their argument is that, insofar as pediatric neuroenhancement is happening, it is better to explicitly acknowledge, monitor, and manage it under the supervision of a pediatrician and parents than to allow minors to self-medicate completely unsupervised. Currently unauthorized neuroenhancement is potentially dangerous and open to abuse. Practices like recreational stimulant use will surely not be eliminated by including neuroenhancement among the services offered by pediatricians. On the other hand, some illicit users use stimulants for neuroenhancement, and insofar as these users could alternatively access stimulants through a pediatrician, wider acceptance of neuroenhancement within the medical community could mitigate the dangers of illicit use.
There are other advantages to recognizing pediatric neuroenhancement as well. If neuroenhancement were recognized as a legitimate reason for stimulant use then pediatricians may alter their prescribing behavior from the level of stimulants that are necessary to benefit a patient with ADHD to a (presumably lower) level of medication for children without ADHD. In addition, recognizing neuroenhancement in the medical context could encourage parents to play a more active role in monitoring their children’s drug use, at least relative to the current practice of illicit use. For example, if neuroenhancement were available through legal and legitimate channels, children may not illicitly use others’ medicines but would instead discuss the possibility of neuroenhancement more openly with their parents and pediatrician. Patients will also benefit from the recognition of neuroenhancement as a distinctive reason for stimulant use. Rather than experimenting with their own dosages of prescribed medication, they may ask a physician for advice about the best brand and quantity of medication for their needs. School-aged children may also benefit from greater acceptance of neuroenhancement insofar as it provides another source of support for struggling students by establishing a more frequent relationship with a medical professional to monitor academic and social development.
The current system of regulating neuroenhancement is not only inadequate because recreational users manage to access stimulants despite legal prohibitions and to use them in potentially inadvisable ways. Another reason that the current system is inadequate is that it regulates nonmedical stimulant use largely through the criminal justice system rather than through health professionals. To prevent hoarding of stimulants for illicit nonmedical uses, the Drug Enforcement Agency enforces quotas on substances like mixed amphetamine salts, which are used to make drugs like Adderall. One widely discussed problem with quotas is that they cause drug shortages that make it difficult for patients with ADHD to access treatment (Clarke 2012; Harris 2011). Yet, quotas are also inappropriate because public officials are not well-suited to determine whether neuroenhancement is warranted for an entire population. Perhaps some nonmedical stimulant users inappropriately use the drugs. Others may significantly benefit. A one-size-fits-all approach to nonmedical stimulant use not only violates adult patients’ rights, it is also as inappropriate as a set of uniform guidelines for medical users would be. Instead, pediatricians who are familiar with particular patients’ needs should determine whether nonmedical stimulant use is warranted just as they are empowered to determine whether medical stimulant use is warranted. Moreover, if public officials are concerned not with nonmedical use but with illicit use then providing a legal path to access for nonmedical users would likely mitigate illegal use, just as repealing other prohibitive policies has historically diminished black markets.
The Rights of Autonomous Adolescents
So far my argument has focused on nonautonomous patients. For autonomous and nearly-autonomous pediatric patients the case for a path to access for neuroenhancement is even stronger. Teenagers have especially strong claims to access neuroenhancing drugs because in many cases they are capable of informed consent. Teenagers’ capacity to give medical consent remains controversial, but many bioethicists, psychologists, and pediatricians have suggested that mature adolescents should be considered medically autonomous (American Academy of Pediatrics Committee on Bioethics 1995; Grisso and Vierling 1978; Leikin 1989; Weithorn and Campbell 1982). Especially considering that mature adolescents are typically able to understand the risks and benefits of a treatment decision as well as adults and that some minors are routinely trusted to care for younger children as babysitters, granting adolescents fewer medical rights than other medically competent people is unjustified (Koren et al. 1993). For these reasons, at least some if not all teenagers ought to be considered capable of giving informed consent.
For some kinds of medical decisions teenagers’ rights of informed consent are respected. For example, teenagers are generally permitted to refuse serious and burdensome medical interventions—even if those interventions are medically advisable. Elsewhere I have argued that the considerations that justify the doctrine of informed consent also justify rights of self-medication (Flanigan 2012). The same considerations that justify giving patients the normative authority to make risky refusal decisions, such as refusing insulin treatment for diabetes, also justify a right to access potentially risky treatments, such as insulin treatment for diabetes. This argument explains why prescription requirements for healthy adults are impermissible, and healthcare professionals should not act as gatekeepers for neuroenhancers for adults. Competent patients should be permitted to take medical risks without a physician or public official acting as a gatekeeper to decide whether the risk is acceptable. Insofar as teenagers are capable of informed consent, this argument also justifies access to neuroenhancements for teenagers, who should similarly be exempt from prescription requirements.
On the other hand, there is also some evidence to suggest that teenagers are not fully capable of informed consent but that they instead occupy a middle ground between childhood and adulthood (Arshagouni 2006; Piker 2011). Insofar as this is true, a middle ground policy solution is warranted—pediatricians should still be empowered to assess young patient’s competence and where necessary to monitor the effects of stimulant use or limit access. However, parental permission should not be required for teenage neuroenhancement just as it is not required for treating ADHD in adolescent patients (Subcommittee on Attention-Deficit/Hyperactivity Disorder 2011).
A case that is analogous to teenage neuroenhancement is teenagers’ right to access prescription contraception without parental permission, which is legal in most states. In a recent survey, 94 % of ob/gyns surveyed reported that they would provide contraceptives to an adolescent patient without parental notification (Lawrence et al. 2011). In this case, it is permissible to prescribe birth control to teenagers so that they can attain the nonmedical benefit of sex without the possibility of pregnancy. This benefit can be achieved in other ways, by using condoms or abstaining from sex, but teenagers, like other contraception users, may have good reasons to prefer contraception to the alternatives, and there is evidence to suggest that parental notification requirements for prescribed contraception would not impede girls’ use of health services more generally (Reddy 2002). Parental permission for contraception use should not be required because some parental notification may violate patients’ privacy and parents may disagree with their teenager’s decision to have sex or use contraception (Helitzer et al. 2011; Perriera and Greenfield 2012). Instead, pediatricians should seek to involve parents in discussions about contraception. Ultimately, however, they should work with patients to determine whether birth control and contraceptive use is advisable.
Correspondingly, some teenagers may seek nonmedical benefits like neuroenhancement. The benefits of neuroenhancement can be achieved in other ways such as by accessing private tutors or foregoing a part-time job to allow for more studying, but teenagers, like other stimulant users, may have good reasons to prefer a pharmaceutical solution. Parental permission for neuroenhancement in these cases should not be required because parents may disagree with their child’s decision to use neuroenhancements. Instead, as stated previously, pediatricians and teenage patients should decide together whether neuroenhancement is appropriate given the patient’s overall circumstances, including her medical and nonmedical well-being.
Within the current framework of pharmaceutical regulation, facilitating teenagers’ access to neuroenhancement without parental permission is at least beneficent, if not supererogatory. It is especially praiseworthy for pediatricians to facilitate teenagers’ requests to access neuroenhancements if teenagers are indeed medically competent because doing so corrects for the violation of their rights to self-medication.
Pediatric Neuroenhancement in Practice
These three arguments justify greater access to and acceptance of neuroenhancement for young people. However, I do not mean to suggest that the practice of pediatric neuroenhancement should necessarily increase but rather that the judgment of whether to prescribe enhancing drugs should be left to pediatricians, patients, and patients’ families. This proposal raises several practical concerns about the growing acceptance of neuroenhancement. Some claim that neuroenhancement cannot be sufficiently distinguished from recreational use, and that children should not have access to drugs for recreational purposes. Another practical objection is that parents or children could be coerced to embrace neuroenhancement. Some of these objections have merit and pose challenges to the practice of pediatric neuroenhancement, but they do not necessarily recommend against neuroenhancement as much as they tell in favor of some limits on marketing and access.
Before I consider these objections though, it is worth emphasizing that other areas of pediatrics lend further support to the foregoing proposal. Cosmetic surgery, which carries significant medical risks and no medical benefits, is generally accepted in most countries as long as patients and parents of the patients consent to treatment (Gilbert 2009). Teenagers with gender identity disorder are permitted to access hormonal therapy even when it is not strictly medically necessary (Giordano 2008). In some cases, children are even permitted to enroll in clinical trials that offer no medical benefits to the patients (Field and Berman 2004). These practices presuppose the arguments that I have presented in favor of pediatric neuroenhancement—they recognize that health is not all that matters to patients and their families and that sometimes pediatric patients can assume medical risks for non-medical benefits.
On the other hand, there are other practices that may seemingly tell against pediatric neuroenhancement. For example, children are not permitted to purchase and drink alcohol or to smoke cigarettes, even if they and their families agree that doing so would benefit the child on balance. One may similarly charge that children should not be permitted to access a drug that is widely used recreationally, and that neuroenhancement cannot be adequately distinguished from recreational use. Once the goal of stimulant medication is reframed as a way of improving patients’ lives on balance rather than as a way of correcting for a medical condition like ADHD then it becomes difficult to distinguish neuroenhancement for an academic or social benefit from recreational stimulant use.
My proposal that the current framework for medical decision making in pediatrics be adapted to accommodate neuroenhancement addresses this concern to some extent.8 If a pediatrician suspects that a patient is likely to misuse or abuse a prescription she can permissibly decline to prescribe the medication to an underage patient. Risky recreational use of prescriptions by nonautonomous minors is an important concern, but this concern should not be limited only to non-medical users. If anything, patients with ADHD are more likely to misuse drugs recreationally, and they already have access to the medicines that are used as neuroenhancements (Charach et al. 2011; Lee et al. 2011). There is also some evidence that this concern is overstated. Stimulant use does not increase one’s likelihood of illegal substance abuse (Barkley et al. 2003). Also, unlike other addictive recreational drugs, there is no evidence of addiction in the 60 years that Ritalin has been prescribed, so there is little reason to think that expanding access to Ritalin would lead to a spike in stimulant abuse (Hall and Lucke 2010).
Another practical concern about expanded access to neuroenhancement is that pharmaceutical advertisements will lead parents or teachers to develop overly optimistic expectations about neuroenhancements. Concerns about the influence of advertising are yet another reason to empower pediatricians to decide when neuroenhancement, or ADHD treatment for that matter, is appropriate for a patient. If parents and patients are not adequately informed about the risks of stimulant medication relative to the benefits it is the duty of pediatricians to inform them before prescribing treatment. It is also important to emphasize that informed consent requires that parents and patients be notified of non-pharmaceutical alternatives before they commit to neuroenhancement (MacDonald and Poirier 2010).
I argued in this essay that neuroenhancement for teenagers should not require parental permission just as parental permission should not be required for teenage contraceptive prescriptions. Still, one may be concerned about advertising neuroenhancements to teenagers. In this case, if the patient is autonomous then truthful advertising should be permitted, just as direct-to-consumer advertising to competent adult patients is permitted on the grounds that it facilitates informed consumer choice. If teenage patients are nearly autonomous then pediatricians can mitigate the influence of misleading advertisements by further educating patients about the risks or withholding access to prescriptions when necessary.
Authenticity and an Open Future
Saskia Nagel and William Graf caution that pediatric neuroenhancement could also disrupt children’s authenticity. They write,
‘‘Developing authenticity’’ during childhood requires genuine individual and social experiences and parental guidance through personal and moral struggles or dilemmas.... Shaping a child’s identity by means of neuroenhancement would be an onerous parental imposition. Some enhancement interventions may promise to help the development of a more authentic self. But paradoxically, in some individuals enhancement might do so by intervening in the child’s personality and thus by changing fundamental parts of the very elf that should be supported to live authentically (Graf et al. 2013).
Other medical ethicists and political philosophers express similar concerns that pediatric neuroenhancement could undermine a child’s right to an open future (Mauron and Hurst 2010; Singh and Kelleher 2010). Political philosopher Michael Sandel worries that enhancement would make parents less accepting of unenhanced children and that parents’ ‘‘openness to the unbidden’’ would be lost in a world of pediatric enhancement (Sandel 2009).
Accepting these arguments against medication has a high intuitive price because neuroenhancement is relevantly similar to either education or ADHD treatment with regard to these objections. First, consider the concern that pediatric neuroenhancement is particularly troubling because it may change a developing child’s personality permanently. Although, it may also make some patients more authentic than their unenhanced selves. This objection assumes that authenticity is a value, but for some people it may not be. Even if authenticity were valuable (whether patients valued it or not), the value of authenticity could still be outweighed by other values. For example, if a patient with ADHD is subjected to bullying and social exclusion because she behaves in a way that she thinks is in line with her authentic self, she may still reasonably seek to develop a more inauthentic self through medication. Similarly, if a healthy patient’s authentic self has difficulty meeting academic or social expectations she may reasonably decide that authenticity is overrated.
In addition, the same threat to authenticity is present in patients with ADHD. Some reject the personality changes associated with medication whereas others embrace them. The differential effects of stimulants on developing authenticity vary in patients who use them for nonmedical and medical purposes. For children, this consideration tells in favor of including a pediatrician in the decision to use stimulants so that the pediatrician can closely monitor a patient’s development.
The ‘‘open future’’ version of this objection, if it succeeds against neuroenhancement, also tells against certain forms of religious education or moral development. Some commentators have suggested that parental rights to develop their children’s intellectual and moral faculties be limited for this reason. For example, Alex Mauron and Samia Hurst begin with the premise that pediatric neuroenhancement should be limited or regulated because of its potentially lasting effects on developing patients’ capacities and opportunities in the future (Mauron and Hurst 2010). They conclude that the same reasons also tell in favor of the regulation of ‘‘malignant education’’ like homeschooling or faith-based education, which also allegedly diminish children’s capacities and opportunities. Even if Mauron and Hursts’s argument is valid, the opposite inference should be drawn. Neuroenhancement is relevantly similar to education in that it is a way of increasing healthy children’s cognitive abilities. Insofar as we allow (within limits) educational choice even when it poses some risks to a child’s authentic development, so too should neuroenhancement be permitted (within limits) even if in some cases it also undermines authenticity.
Finally, Sandel worries that pediatric enhancement could threaten parental acceptance of their children or their ‘‘openness to the unbidden’’ (Sandel 2009, p. 46). Sandel focuses on the impact of genetically engineering children, but notes that pediatric neuroenhancement similarly compromise the parent–child relationship (Sandel 2009, pp. 59–61). Yet, Sandel’s concern for parent–child relations could also tell in favor of neuroenhancement. For children with ADHD, medication has a beneficial impact on parental-child interactions (Danforth et al. 1991). If the effects for patients without ADHD are similar, then neuroenhancement may benefit the parent–child relationship. Sandel also worries about parents’ acceptance of unenhanced children, though. Yet, as Francis Kamm replies, it is not inconsistent to accept one’s child as ‘‘given’’ as long as she is sufficiently endowed, while nevertheless seeking to provide the best set of opportunities for that child (Kamm 2005). That is, as long as one’s child would be accepted if she remained unenhanced, seeking enhancement is not incompatible with accepting one’s child.9 In addition, Sandel’s rejection of neuroenhancement reflects a dubious distinction between disadvantages that are rightly corrected with medication (like infectious diseases or ADHD) and nonmedical disadvantages that are inappropriately corrected with medication (Kamm 2005; Mcconnell 2011).
Concerns about the parent–child relationship in light of neuroenhancement have more force when we consider the possibility of parental coercion. One family that reported prescribing stimulants to their children for nonmedical reasons reported that ‘‘My kids don’t want to take it, but I told them, ‘These are your grades when you’re taking it, this is when you don’t,’ and they understood’’ (Schwarz 2012). It is difficult to say whether this kind of parental pressure constitutes coercion, but it is easy to imagine that parents could pressure or even force their children to use prescription drugs against their child’s wishes. Like other forms of parental coercion, their motives may be benevolent or they may be motivated to make their own lives easier. Parental coercion can also be influenced by advertising. For example, advertisements for stimulant treatments such as Vyvanse, an ADHD drug, already depict parents saying things like ‘‘I want to do all I can to help him succeed,’’ which some physicians attribute to the increased treatment of even minor ADHD symptoms (Schwarz and Cohen 2013).
However, as Francis Kamm points out in her discussion of genetic enhancement of children, even if parents exercise more control over their children’s lives by choosing to pursue enhancements, insofar as an enhancement increases self-control or good judgment it could effectively shift the balance of control over a child’s life from the parent to the child (Kamm 2005). Still, parental coercion will remain a concern when a patient withholds consent or assent to the initial treatment decision or to continued treatment, and in these cases pediatricians should discuss neuroenhancement privately with young patients and withhold access when the patient does not assent.10 Sandel’s concern about parents’ perceptions of unenhanced children further supports establishing a framework to limit parental coercion, but concerns about the parent–child relationship do not warrant limiting the prescription of neuroenhancement to children more generally.
Expanded Access and Social Justice
Another serious concern surrounding pediatric neuroenhancement is that it will undermine social justice by increasing socioeconomic inequalities or further limiting the opportunities of the worst-off, for example. Some proposed solutions to this concern have been to allow equal (publically subsidized) access to neuroenhancements or to limit access to neuroenhancements to only the disadvantaged. Others object that equal access to neuroenhancement is unwarranted because while patients have equal rights to access necessary medical treatment, they do not have equal rights to elective procedures. From a social justice perspective, however, neuroenhancement is better understood as analogous to education rather than medical treatment. Therefore, insofar as children have equal positive rights to access an education they should also have rights to equal access to neuroenhancements. On the other hand, if parents of school-aged children have rights to refuse to adequately educate their children they should also have the authority to refuse to provide their children with access to neuroenhancement.
Some critics of pediatric neuroenhancement claim that it will further exacerbate existing educational inequalities. I argued that neuroenhancement might instead correct for educational inequalities by enabling students to succeed in failing schools with distraction-filled environments, but neuroenhancement can only achieve this goal if all children have equal access to neuroenhancement regardless of their ability to pay. This would require that all children had equal access not only to neuroenhancements themselves, but also to reliable pediatric care for monitoring the use of neuroenhancements. Such a proposal should strike advocates of social justice as relatively uncontroversial because it entails that all children, regardless of income, should have access to health services. Relative to non-pharmacological neuroenhancements like supplemental tutoring or private schools, medicines are easier to provide. Most states already have a framework for providing health services to all children, and so insuring equal access to neuroenhancement only requires that states expand those services to include prescriptions for nonmedical users.
One concern about this proposal is that states and educators may rely on pharmacological solutions to educational problems rather than correcting the underlying problems. I am not arguing that states should ignore the inadequacies of the current education system, but given the failings of many school systems states should not further stand in the way of students who seek greater opportunities. States undermine children’s opportunities through poor educational policy and an overly narrow approach to neuroenhancement. Both policies are an injustice to children who struggle in inadequate schools; correcting one injustice does not let states off the hook for the other.
Another concern about this proposal is that pediatric neuroenhancement will not address inequality insofar as it is available to all children, but rather that it will simply raise the standards to be competitive across all socioeconomic levels. As a potential solution, Ori Lev considers that a just distribution of neuroenhancements may require that they only be provided to those with poor educational prospects as a way of promoting equal educational opportunities (Lev 2010). Such a proposal assumes that everyone should have equal educational opportunities. Because the value of one’s education depends on the level of education held by others, egalitarians worry about policies that could enable advantaged families to further expand their children’s opportunities, thereby worsening the gap between the best- off and the worst-off (Brighouse and Swift 2006).
I am skeptical of the assumption that justice requires equal educational opportunities. Rather than focusing on equal opportunities, states should concern themselves with providing adequate opportunities for all children. Even if equal opportunity is a value, it is not the kind of value that can justify limits on parents or patients’ autonomy when it comes to neuroenhancements. Just as it would be unwarranted to ban private schools because students in those schools would gain a positional advantage over public school children, so too would it be impermissible to limit parents’ and children’s autonomy by prohibiting advantaged patients from accessing neuroenhancements. In any case, the value of one’s education need not depend solely on the level of education attained by others. Education and enhancement can have both positional and absolute value. Allowing private education may raise the absolute level of educational achievement in a society while also increasing educational disparity. If the absolute gains in achievement are significant enough these gains may justify increasing disparity. Similarly, even if allowing neuroenhancement did heighten educational disparities, the absolute benefits of allowing neuroenhancement could justify greater inequality.
Conclusion
I have argued for a path to access pediatric neuroenhancement. The current framework of consent in pediatrics already allows for elective medical procedures, such as cosmetic surgery and hormone therapy. Pediatricians also have a well-established framework for prescribing stimulants to children with ADHD to enhance their academic performance. Yet these practices, which are accepted and pervasive in pediatrics, have not been extended to pediatric neuroenhancement. Non-pharmaceutical forms of academic enhancement are pervasive as well. Given that parents and pediatricians already accept many nonmedical forms of academic enhancement and many other kinds of medical enhancements, pediatric neuroenhancement should also gain wider acceptance.
For these reasons, I have argued that the existing frameworks that govern elective interventions and ADHD treatment can and should be adapted to accommodate nonmedical academic enhancements as well. There are also practical reasons in favor of this proposal. Acknowledging neuroenhancement in pediatricians’ offices may lessen misdiagnoses of ADHD and diminish black markets in neuroenhancements. Teenagers’ claims to use neuroenhancements are especially strong because they are autonomous or nearly autonomous. Concerns about addiction, misinformation, authentic development, the parent–child relationship, or educational equality are generally misplaced when presented as reasons for limits to neuroenhancement, but these concerns may inform how pediatricians approach neuroenhancement with patients and their families.
Footnotes
Children in the US consume three times more ADHD medication than the rest of the world combined (Mayes et al. 2008). As many as 66.3 % of American children with an ADHD diagnosis receive medication for the disorder (CDC—ADHD, Data and Statistics 2013). Still, the global market for ADHD drugs has quickly expanded in the last decade, which indicates that the rising prevalence of ADHD diagnosis and medication is a global phenomenon (Scheffler et al. 2007).
Studies indicate that 35% of college students have used ADHD medications without a prescription, usually as a study aid (Low and Gendaszek 2002).
Greeley et al’s commentary set off a wave of letters to the journal, some in enthusiastic support of pharmaceutical means of enhancement and some urging greater caution and questioning the benefits (Anonymous 2009a, b; Chatterjee 2009; Williams and Martin 2009; Young and Colpaert 2009).
The lack of good evidence about neuroenhancement is especially problematic because healthy brains may be different than brains of people with ADHD, and the standard course of treatment and dosage levels may vary as well (Singh and Kelleher 2010). On this point, I leave it as an open question whether healthy pediatric patients should be enrolled in clinical trials. I suspect that it is permissible to enroll healthy children in clinical trials that could provide them with nonmedical benefits, for the reasons I develop in this essay. Here I only mean to highlight the basis of a common objection to neuroenhancement, which is the lack of evidence.
While there may be some reason to think that the effects of stimulants on a child without ADHD will be more dangerous because of biological differences, this hypothesis also has not been well established and some parents and patients may be willing to tolerate higher risks than those associated with ADHD treatment to attain the benefits of neuroenhancement.
Or possibly, if the patient experiences relief of her symptoms after using the drug while similarly situated patients did not experience relief while using a placebo. On the other hand, perhaps placebos may be reasonably classified as effective treatments by this standard.
Dr. William Graf, a pediatrician at the Yale School of Medicine affirms this recommendation in a report about ADHD in the New York Times. Graf suggest that pediatricians ought to be permitted to prescribe stimulants to non-ADHD children as long as they closely monitor the side effects (Schwarz 2012). On the other hand, Graf is also an author of the position paper for the Ethics, Law, and Humanities Committee endorsed by the American Academy of Neurology that recommends against pediatric neuroenhancement, so Graf’s all-things-considered judgment remains unclear (Graf et al. 2013).
One might question whether the current framework is justified. For example, an anonymous reviewer suggested that parents, not pediatricians, should be empowered as gatekeepers to treatment. My aim in this essay is not to question the current system of pediatric decision making but rather to show broadly recognized standards for children’s medical treatment can and should be adapted to accommodate neuroenhancement as well.
This reply may assume that the child remains essentially the same person whether she is enhanced or not. For neuroenhancements that go beyond stimulant medication, one may worry that encouraging a child to take drugs that will significantly transform her identity are incompatible with an attitude of accepting the child’s existing identity. If this objection succeeds then a defense of transformative pediatric neuroenhancement must show that other considerations can take priority over unconditional acceptance of a child’s identity or that parents’ unconditional acceptance of a child’s identity is not very morally significant.
Some critics are skeptical that pediatricians will be well placed to screen parents for vulnerability to advertisements and social pressure or to assess whether a parent is acting coercively (MacDonald and Poirier 2010). If pediatricians are not well placed to make these assessments, social workers or interdisciplinary gatekeepers may be appropriately involved in the case (Gini et al. 2010). The solution to parental ignorance is not that all parents and patents, however informed, ought to be prohibited from pursuing pediatric neuroenhancement because some parents will be uninformed any more than the solution to the fact that some patients are ignorant is not to prohibit all patients from making treatment decisions.
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