Should we pass on the clever pills?

Capsules. Anna Tanczos / Wellcome Images

Capsules. Anna Tanczos/Wellcome Images

If we can drink coffee to improve our concentration, why not take cleverer drugs to make us cleverer? At our discussion event about cognitive enhancement in February, Lydia Harriss was on hand to consider some thorny issues.

Would you take a pill to help you pass an exam?

“Definitely not!” I hear at least some of you say, bristling with indignation at the mere suggestion. That would be cheating, like an athlete taking performance-enhancing drugs before a competition. But are there occasions when using cognitive-enhancing drugs – which improve mental functions such as memory, attention and information processing – would be acceptable, or even desirable? A lively discussion at ‘The Clever Pill’, in February’s series of events on neuroethics at Wellcome Collection, made me think that there might.

What if cognitive-enhancing drugs (let’s call them CEDs) could be used to restore cognitive function in people who have lost some of their mental ability through injury or illness? Arguing against their use on purely ethical grounds, I think, would be difficult. Cries of ‘unfair advantage’ would seem churlish if a drug had the potential to improve a person’s quality of life, particularly if it were compensating for the loss of an ability that they’d originally had.

How about non-therapeutic situations? Are there some professionals who we should allow to use CEDs under certain, tightly regulated, conditions? Panellist Dr James Rowe, Clinical Neurologist and Wellcome Trust Senior Research Fellow, suggested that surgeons working on nightshifts could be good candidates. Perhaps they should have the option of taking CEDs to improve their attention and judgement for emergency night-time operations, when patients’ lives depend on accuracy and clear thinking but surgeons are likely to be more tired. That could be a win–win situation: the patient benefits from an operation that is performed as well as it can be, and the surgeon is elevated to a level of heightened skill.

But would it really be that simple? It would be difficult to claim that surgeons would have an ‘unfair advantage’ in this scenario, given that patients would be the main beneficiaries. However, there are other, more sinister, potential consequences… can you hear those slithering noises? They’re coming from a shiny can labelled ‘side-effects’. I’m afraid to lift the lid, as I suspect there are way more worms in there than I can deal with, but let’s be brave and take a tiny peek.

Side-effects are always a consideration where drugs are concerned. Researchers can do clinical trials to investigate the effects of a drug over a few years, but it becomes much harder to look at how humans respond to it over decades or a lifetime. So, realistically, there’s probably always some possibility, no matter how remote, of a person having an unintended reaction to a drug.

When drugs are taken as medical treatment, the potential benefits (which are often substantial) can be weighed against the possibility of adverse side-effects. But is it fair to allow our hard-working surgeons, who are running themselves ragged trying to save lives, to accept the risks associated with CEDs if there’s no personal benefit to their own health?

We could leave it up to individual surgeons to make a personal decision (assuming that the CEDs in question have passed the efficacy and safety tests required for new drugs). Surely professionals should have the freedom to decide whether CEDs are a useful tool that can help them in their work?

However, there’s another possible consequence rearing out of the increasingly murky waters of this debate – coercion. If more and more surgeons take CEDs, it seems likely that some individuals who would otherwise not want to take them could feel compelled to, under the weight of social expectation or the fear of falling behind in their careers.

When the debate swivels around to the idea of making CEDs freely available to everyone, the issues become even more complex. Perhaps CEDs could help us to more fully achieve our potential? They could enable us to be more productive, creative and clever.

Panellist and Senior Research Fellow at the Oxford Martin School’s Institute for Science and Ethics, Dr Bennet Foddy, pointed out that a huge number of cognitive enhancers are already in wide use throughout society. They include caffeine, carbohydrate-rich food, exercise and sleep. He suggested that there isn’t a moral distinction between taking a drug and using an alternative form of cognitive enhancement.

That may be true, but it seems to me that most of these other alternatives are widely available. I could choose to go for a run after work to boost my mental processes. If I decide that I’d rather spend the evening crashed out on the couch watching TV, then I’ve chosen to miss out. But if a wonder pill did exist that could significantly boost mental performance, it would probably cost money, and that brings with it the prospect of inequality. Would we find ourselves with an even more profoundly divided society, with intellectual disadvantage compounding existing economic privations? Without a crystal ball, it’s difficult to tell, but I wasn’t the only person in the audience who thought that it might.

I was intrigued to hear Professor Simon Wessely, Professor of Psychological Medicine at King’s College London, give his views on currently available CEDs. It felt like a sharp reality check. He said that the cognitive-enhancing effects provided by today’s drugs are very modest, and that even the longest-lasting effects wear off within about 12 weeks.

According to Dr Rowe, research suggests that CEDs tend to have the greatest effect on people with a below average IQ or those who have a temporary loss of cognitive ability – for example, through tiredness. This could mean that some of the people most tempted to take enhancers, such as high-performing students under pressure to succeed, may be less likely to benefit from them. Dr Rowe seemed to succinctly sum up the situation when he said that the benefits from a good night’s sleep, social networking and exercise will outstrip those from any of the drugs currently available.

Significant and lasting cognitive enhancement through drugs seems to be well beyond the reach of current research. After hearing the knotty issues surrounding CEDs, I’m rather relieved to hear that we don’t have the ability to lever open this particular Pandora’s Box just yet. However, it’s clear that there’s much to consider if one day we do.

Lydia Harriss is a graduate trainee at the Wellcome Trust.

Object of the Month: Blade Runner

Guillotine blade used in execution of Jean-Baptise Carrier.  French, 1790-94

Guillotine blade used in execution of Jean-Baptise Carrier. French, 1790-94. Science Museum/SSPL

For a man so interested in the history of health and wellbeing, it is remarkable just how many torture devices, weapons and instruments of execution found their way into Henry Wellcome’s vast collection of between 1 and 2 million medical and anthropological curios. From African spears to amputation saws and from trepanned skulls to torture chairs, Wellcome’s collection served not only as a grizzly catalogue of medicine’s past attempts to heal and cure but as an unsettling reminder of how knowledge of the human body can be used to cause just as much harm as good. By placing these gruesome offerings alongside more traditional symbols of ‘good medicine’ – the stethoscope, the medicine chest – Wellcome’s collection quietly challenged the ethical authority of Western medicine, with its famous claim, enshrined in the Hippocratic Oath, to ‘do no harm.’

The truth is, as Henry Wellcome surely realised, medicine has never been solely about the preservation of health and life. In various political and religious circumstances, medical knowledge can be co-opted to deliberately cause harm or take life away, from the horrific Nazi concentration camp experiments to the cool clinical practice of Death Row in America. Medicine’s ethical integrity in regard to the taking of life continues to be questioned in the 21st century: recent controversy erupted when it was discovered a British pharmaceutical company was selling a drug to be used as part of the lethal injection in the United States, and the place of medicine in euthanasia or abortion is still fiercely debated.

All these issues buzz around this month’s item, a guillotine blade used during the French Revolution, on display in Medicine Man. Surprisingly small (nowhere near the size of the contraptions usually seen in magic tricks or in films) the reason it found a home among Wellcome’s more overtly medical artefacts was as simple as the device itself: its use was suggested as a more swift, clinical, medical way of executing people during the Revolution by the eminent physician, Joseph-Ignace Guillotin (1738–1814).

The circumstances of Guillotin’s birth couldn’t have been more grimly prophetic. Prior to the Revolution, a variety of methods of execution were used in France, and one of the most feared was the breaking wheel, which cudgelled its victims to death. According to Guillotin family legend, it was the shock of hearing the blood-curdling cries of a man being broken upon the wheel that led to Guillotin’s premature birth. Guillotin grew to be a wealthy and respected physician, renowned for his rationalism and reformist attitudes. Along with Benjamin Franklin, in 1784 he was a member of the inquiry that investigated Franz Anton Mesmer’s theory of animal magnetism, and he dallied with ideas of political reform before turning his attention to the reform of capital punishment in 1789. It was Guillotin’s belief that, as a first step towards abolishing capital punishment altogether, a more humane and egalitarian form of execution was required in France to replace the torturous and class-based punishments handed out in the ancien régime: in general, the aristocracy was afforded the dubious honour of decapitation by sword, while commoners were usually hanged. To this end he proposed a ‘simple mechanism’: ‘The device strikes like lightning, the head flies, blood spouts, the man has ceased to live,’ he argued.

It is a myth that Guillotin designed and built the blade before later falling victim to it (he died quite peacefully in 1814, although he did narrowly escape his own death by it). The French guillotine blade was designed by a surgeon, Antoine Louis, and built to specification by a German maker of musical instruments. In fact, if it wasn’t for a popular Royalist satirical song of the day, Guillotine’s name would probably have never become attached to the device; instead, it probably would be known to this day as the Louisette or Petite Louison, after the surgeon who designed it. The ‘Guillotine’ wasn’t even the first decapitation machine. Forms of the guillotine had been in use in Europe for centuries before the French Revolution: the Maiden in Scotland and the Gibbet in Halifax were two methods used in Britain (if someone was caught stealing a sheep in Halifax, a sheep would be brought in as the executioner, releasing the rope that unleashed the blade).

The guillotine blade on display in Medicine Man was used to execute an infamous revolutionary, Jean-Baptise Carrier. Carrier was renowned for the sadistic ways he despatched his enemies, such as the drowning of political prisoners in the River Loire. It often isn’t realised just how recently execution by guillotine was practised in France: the last guillotining (in private) took place in 1977, to execute a Tunisian murderer called Hamida Djandoubi. The last public guillotining took place in the 1930s; it was only in 1981 that France withdrew the death sentence altogether.

Some historians have argued that Guillotin was a humanitarian, since he suggested the use of an instrument that did away with forms of execution that were crueller and more protracted by comparison. In this sense, perhaps the guillotine can be considered a ‘medical’ object of sorts, and more at home with its surrounding objects than it may appear. On the other hand, the guillotine allowed people to be unthinkingly executed on a terrifying scale – 40,000 people during the French Revolution alone. Can a device which led to so many deaths in any way be considered ‘medical’?

Chris Sirrs is a Visitor Services Assistant at Wellcome Collection.