The Fear of the Pill: Common Misunderstandings of Performance-Enhancing Medications — by David Mou
Twenty years from now, a pharmaceutical company introduces the ‘Magic Pill’, a drug that can improve a healthy person’s intelligence by 50% with negligible side effects. My fellow classmate, Joe, begins using the pills. In preparation for the Board Exam, I put in months of hard work, but with the aid of the pills, Joe needs to study only a few days to get the same score I did. Instinctively, I feel wronged and cheated.
The extraordinary strides science has made suggest that the pharmaceutical industry will continue the trend of producing new drugs with ever-greater potency and ever-fewer side-effects. Psychoactive drugs have also become safer throughout the years. Monoamine oxidase inhibitors (MAOIs) used to be the first-line treatment for mental disorders in the fifties and sixties, but serious side effects such as sedation and toxicity limited their popularity. They were succeeded by the selective serotonin reuptake inhibitors (SSRIs), which caused considerably fewer unwanted effects. Soon we may have pills that increase our memory capacity, allow us to become more creative, or alter our personalities as we wish. The Magic Pill might remain hypothetical for only so long.
However, as the case with Joe illustrates, Americans are growing increasingly wary about the behavior of ‘popping pills’ in an attempt to solve life’s problems. How could taking pills to score higher on the SAT possibly merit the same praise as simply putting in the effort and studying hard? What place do doctors have in prescribing enhancements, when their real task is to cure disease? And how unnatural is it for us to alter a patient’s intelligence or personality? Bioethicist Leon Kass introduced the ‘wisdom of repugnance’: if we intuitively react against an idea with distaste, the idea itself must be an immoral one. But such a simplistic method of judging moral worth ignores the nuances and intricacies of ethical dilemmas. If instincts alone determine the direction of our moral compass, even racism and anti-Semitism could be justified. Should our instincts flare in opposition to an idea, it is only safe to conclude that the topic requires further investigation. We harbor certain presumptions that predispose us to become instinctively averse to drugs like the Magic Pill. But upon closer inspection, these responses are unreasonable. Furthermore, they may serve to limit our receptiveness towards new and powerful technologies that may dramatically improve our quality of life.
To understand better why many people instinctively recoil at the idea of the Magic Pill, it is instructive to examine exactly how we conceptualize the idea of cheating. Cheating can take on varying meanings in different activities. If we fail to recognize these nuanced differences, we run the risk of incorrectly imposing context-specific ethical judgments on situations where such judgments are not valid.
For many, competition in sports informs how fairness is understood. In competitive sports, the difference between cheating and enhancement is significant. Sports are a way to display the abilities of the human body while celebrating values such as effort, sportsmanship, and teamwork. The use of steroids detracts from this goal. Furthermore, given how competition is inscribed in the DNA of most competitive sports, the steroid users’ improved performance could implicitly coerce other athletes to adopt the unhealthy habit in order to remain competitive.
But outside the world of sports, cheating could take on a slightly differing definition. Medicine—and academia in general—serves as an example in which ‘cheating’ should be understood in a different light. The ultimate goal of medicine is to save and improve lives, not to win a competition. Though competition surely exists among labs, hospitals, and universities, it only serves as a means to a greater end.
Certainly, there are acts of cheating that academic medicine does not condone. Falsifying data in order to publish could potentially advance a researcher’s career in the short run, but the act is never permissible because not only does it corrupt scientific integrity, but it may also prove to be harmful to patients down the road. However, researchers could drink as much coffee or sleep as little as they please – and with increased alertness and more hours at their disposal, researchers would be capable of advancing knowledge faster, curing more diseases, and saving more lives. The National Institute of Health’s mission statement consists of “making important medical discoveries that improve health and save lives”. Coffee has played no small part in aiding researchers who seek to realize this mission. The Magic Pill is more akin to caffeine than it is to falsification of data; the drug does confer its users an edge, but unlike the act of falsifying data, its use satisfies the ultimate goal of making discoveries and saving lives with minimal additional risk. As such, although it may be wrong for athletes to dope on steroids, it doesn’t necessarily follow that researchers should not use the Magic Pill. Our understanding of performance enhancement in sports may instinctively guide us to judge incorrectly the moral status of performance enhancement elsewhere.
Another common argument against the Magic Pill concerns our understanding of what is ‘natural.’ But what exactly constitutes ‘natural’? To look at its opposite, ‘unnatural’ is commonly associated with artifice, contamination, or unintelligible chemical names. On the other hand, most people think of ‘natural’ as a positive attribute: ‘all-natural’ orange juice, ‘naturally’ raised chicken, saying she is ‘naturally’ gifted.
For some, ‘natural’ may simply reflect personal experiences and habits. If I observe that everyone around me speaks English, I would consider it ‘natural’ to speak English. Of course, in many societies this is not the case, so my conception of natural would not be universal. The principle holds for more controversial topics as well: if I were brought up in a devoutly religious community where everyone practiced the same religion, I might consider the practicing of other religions unnatural, even immoral. At some level, one’s perception of natural is informed by one’s experiences, observations, and habits. Therefore, arguments that appeal to the ‘natural’ in this sense are inherently biased.
Furthermore, it is worth noting that the perception of ‘natural’ is highly dependent on historical, cultural, and scientific factors. Vaccines are an illustrative example. Vaccines are chemically weakened viruses that can protect people by preparing their immune systems. Before scientists had a clear understanding of how the immune system functions, the idea of injecting a weakened bug—the very agent that causes the disease—into perfectly healthy people would have seemed highly unnatural. Yet today, after vaccines have been shown to be effective, it is considered irresponsible to reject vaccines for children.
So what about this Magic Pill that makes a healthy individual 50% smarter? As the vaccine example illustrates, when science introduces revolutionarily new technology, often the novelty of the idea is sufficient for it to be perceived as unnatural. Having explored the determinants of how we come to understand what is ‘natural’, it is safe to conclude that the division between natural and unnatural is continually shifting. Any concept defined so differently by so many people would not serve well to provide conclusive closure for ethical discourse.
Another gut reaction to the Magic Pill is to equate its use with cheating. What is it about cheating that makes is so morally reprehensible? The cheater on a test commits a number of moral transgressions: he lies to his professor by misrepresenting what he knows, he violates the trust of his fellow classmates by copying their answers, and he can hurt himself (and his future patients) by short-circuiting the learning process and receiving grades that do not reflect his mastery of the course material. But this conventional definition of cheating fundamentally differs from the situation with the Magic Pill. Joe is by no means misrepresenting what he knows. The Magic Pill does not provide him with the answer key for the test; it makes it easier for him to learn the material beforehand, and so his grades are actually a true reflection of his abilities. Joe will do just as well as his colleagues who scored in the same range in the hospital, whereas the cheater would not fare as well.
In discussing the underlying reasons that give rise to the knee-jerk distaste for pharmaceutically driven enhancement, some common themes emerge. First, much of the contention revolves around dichotomous constructs: enhancement vs. treatment, natural vs. unnatural, cheating vs. improving. The attempt to establish a clear-cut line between each pair is a futile exercise because the line itself is constantly shifting. Broad categories such as ‘treatment’ or ‘enhancement’ serve as convenient mental constructs to encompass ideas and actions. The problem with binary grouping is that it gives an impression of absolutism: the Magic Pill is either natural or unnatural. In reality, these judgments of natural operate along a continuum. The Magic Pill may be less natural than Vitamin C supplements, but more natural than invasive brain surgery.
Secondly, these dichotomous constructs are inextricably linked. What is considered ‘natural’ inevitably informs what is considered a ‘disease’. Such overlap further suggests that these categories simply serve as a convenient way to group complex, interrelated concepts, and that the subjective divisions between them cannot be used to resolve ethical issues effectively.
Science and technology will continue to challenge our conception of natural and moral behavior. Habit, consistency, and fear of the unknown can conspire to vilify enhancement technologies as unnatural, invasive, and morally reprehensible. Instead of limiting our perspective to the provinciality of our own experiences, let careful reasoning, rather than the ‘wisdom of repugnance’, serve as our guide.
 Joseph Lieberman, “History of the Use of Antidepressants in Primary Care” J Clinical Psychiatry 2003;5
 Leon Kass, “The Wisdom of Repugnance”
 For clarification, ‘treatment’ will be used to denote medication used to treat a clinically recognized disease, whereas ‘enhancement’ drugs will represent medication used to increase the capacities of healthy patients.
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