SCIENTIFIC CONTRIBUTION

The value and pitfalls of speculation about science and technologyin bioethics: the case of cognitive enhancement

Eric Racine • Tristana Martin Rubio •

Jennifer Chandler • Cynthia Forlini •

Jayne Lucke

� Springer Science+Business Media Dordrecht 2014

Abstract In the debate on the ethics of the non-medical

use of pharmaceuticals for cognitive performance

enhancement in healthy individuals there is a clear division

between those who view ‘‘cognitive enhancement’’ as eth-

ically unproblematic and those who see such practices as

fraught with ethical problems. Yet another, more subtle

issue, relates to the relevance and quality of the contribution

of scholarly bioethics to this debate. More specifically, how

have various forms of speculation, anticipatory ethics, and

methods to predict scientific trends and societal responses

augmented or diminished this contribution? In this paper,

we use the discussion of the ethics of cognitive enhance-

ment to explore the positive and negative contribution of

speculation in bioethics scholarship. First, we review and

discuss how speculation has relied on different sets of

assumptions regarding the non-medical use of stimulants,

namely: (1) terminology and framing; (2) scientific aspects

such as efficacy and safety; (3) estimates of prevalence and

consequent normalization; and (4) the need for normative

reflection and regulatory guidelines. Second, three meth-

odological guideposts are proposed to alleviate some of the

pitfalls of speculation: (1) acknowledge assumptions more

explicitly and identify the value attributed to assumptions;

(2) validate assumptions with interdisciplinary literature;

and (3) adopt a broad perspective to promote more com-

prehensive reflection. We conclude that, through the

examination of the controversy about cognitive enhance-

ment, we can employ these methodological guideposts to

enhance the value of contributions from bioethics and

minimize potential epistemic and practical pitfalls in this

case and perhaps in other areas of bioethical debate.

Keywords Cognitive enhancement � Methods of

bioethics � Speculation � Neuroethics � Reflexivity

Introduction

The debate about the phenomenon of ‘‘cognitive

enhancement’’, namely the non-medical use of pharma-

ceuticals to augment cognitive performance in healthy

individuals, has raised wide-ranging ethical questions and

captured attention within academia and broader society

(Farah et al. 2004; Parens 1998; Greely et al. 2008). This

debate has led to proposals for public policy (Outram and

Racine 2011a, b), to extensive and high profile media

coverage (Forlini and Racine 2009a, b; Boot et al. 2011;

Partridge et al. 2011), to publications for the general public

(Buchanan 2011), and to heated academic exchanges

(Caplan and Elliott 2004; Caplan and McHugh 2004).

There is a clear division between those who are generally

in favor of enhancement and those who see such practices

E. Racine (&) � T. Martin Rubio � C. Forlini

Neuroethics Research Unit, Institut de recherches cliniques de

Montreal (IRCM), 110 Avenue des Pins Ouest, Montreal,

QC H2W lR7, Canada

e-mail: eric.racine@ircm.qc.ca

E. Racine

Department of Medicine and Department of Social and

Preventive Medicine, Universite de Montreal, Montreal, Canada

E. Racine

Departments of Neurology and Neurosurgery, Medicine and

Biomedical Ethics Unit, McGill University, Montreal, Canada

J. Chandler

Faculty of Law, University of Ottawa, Ottawa, Canada

J. Lucke

UQ Centre for Clinical Research, The University of Queensland,

Herston, QLD 4029, Australia

123

Med Health Care and Philos

DOI 10.1007/s11019-013-9539-4

as ethically problematic (Parens 2005; Racine 2010; Forlini

and Racine 2013). This paper focuses on the way that

scholarly bioethics, defined as broadly encompassing con-

tributions from authors with diverse disciplinary back-

grounds such as bioethics, neuroscience, philosophy, and

law, has been conducted in the cognitive enhancement

debate. It examines how various forms of speculation,

anticipatory ethics, and methods to predict trends have

augmented or diminished the relevance and quality of the

work in scholarly bioethics. Some authors are engaging in

the prediction of future outcomes (e.g., benefits or risks of

human enhancement) and trends related to the use of

pharmacological cognitive enhancers (Bostrom and Sand-

berg 2009) and others are criticizing such speculation

(Lucke et al. 2010; Carter et al. 2009).

Speculation, or ‘‘looking out’’ (speculare), involves an

attempt to predict and draw conclusions based on incom-

plete evidence. In this paper, we consider speculation about

the future as an effort to foresee potential or probable

scenarios and their outcomes based on assumptions that

cannot be verified by empirical or scientific claims in the

present. Although this form of ‘‘looking out’’ is future-

directed, the specific act of speculation takes place in the

present, which means that the act of speculation is always

situated within present values and concerns. To ‘‘look out’’

necessarily implies looking out from a particular place, or a

particular point of view, towards an unknown future and

thus, there are multiple ways to ‘‘look out’’. Speculation is

a challenging exercise because of the interdisciplinary and

multi-faceted nature of bioethical inquiries and the com-

plexity of the questions they raise, as is the case with

cognitive enhancement. In addition, we recognize the

positive value of speculation and of creative, forward-

looking, moral thinking to generate responses to ethical

problems posed by biomedical science (Keulartz et al.

2004). Nevertheless, the process is not without pitfalls.

Here, we consider specifically the problems regarding how

some unwarranted speculation has occurred about cogni-

tive enhancement and caused serious detrimental effects

within scholarly bioethics.

In this paper, we use the ethical discussion of cognitive

enhancement as a case study to explore the positive and

negative contribution of speculation in bioethics scholar-

ship. We first establish how speculation was involved in

framing and supporting the debate on cognitive enhance-

ment practices and highlight related concerns. We then

propose and reflect on a number of methodological

guideposts to avoid practices in which speculation runs the

risk of degenerating into unfounded and inaccurate claims.

We argue that claims made about the future practices of

cognitive enhancement be done with clearer factual con-

straints, more awareness, and enhanced self-reflection. We

hope to stimulate further discussion on the methods of

bioethics scholarship with respect to speculation and its

impact on public debate. Other topics such as gene ‘‘ther-

apy’’, xenotransplantation, stem cell ‘‘therapy,’’ nanotech-

nologies, reproductive technologies and other related

technologies, which have raised ethical questions, would

be suitable for similar analysis. The case of cognitive

enhancement is particularly suited for further consideration

because the non-medical use of stimulants is a documented

practice in some regions and offers a unique case study of

how speculative discourses may come to shape concrete

reality (Dresler et al. 2013; ETHENTECH 2012; Neuro-

Enhancement: Responsible Research and Innovation

2013).1

Speculation in discussions about cognitive enhancement

In bioethics, the nature of and justification for speculation

are multifaceted. In some respect, speculation is a delib-

erate effort to conduct proactive ethics. The purpose is to

foresee the major ethical challenges in an effort to mini-

mize harms that may be caused by, in this case, the non-

medical use of pharmaceuticals. In this sense, speculation

is at the root of the early impetus for a renewed biomedical

ethics (Durand 1999). At the same time speculation nec-

essarily relies on unknowns and is a practice that is in

tension with different strands of bioethics (e.g., casuistry,

feminist ethics, narrative ethics) that are committed to

considering the context of ethical issues (Wolf 1994).

On the one hand, a number of authors have identified

what they view as problems stemming from these specu-

lative activities of bioethicists, broadly construed, which

include neuroscientists, legal scholars, social scientists, and

ethicists involved in the debate about the non-medical use

of stimulants (Outram 2012; Ferrari et al. 2012). First,

these critics have claimed that analyses grounded in highly

speculative claims may reflect and encourage technological

determinism as well as values associated with scientific and

technological development. Second, they have posited that

authors who speculate have traded their own responsibility

to critically examine the values involved in different

positions in the debate for a frame of cognitive enhance-

ment built on false assumptions of the safety and effec-

tiveness of enhancers, or the lack thereof. Consequently,

scholars taking an anticipatory ethics approach in the

cognitive enhancement debate have been criticized for

practicing ‘‘speculative bioethics,’’ invoking slippery

1 Our own reflection was part of a project examining the legal, ethical

and social consequences of memory technologies in an effort to

engage in meta-ethical questions about bioethics itself. Some of the

authors of this paper have directly intervened in this debate and

therefore take a reflexive stance on their own scholarship and the

claims made in their contributions.

E. Racine et al.

123

slopes, and conjuring up hyperbolic or unreasonable sce-

narios (Henry et al. 2007; Dees 2004; Launis 2010; Fins

2008; Nordmann 2007). Such a misalignment between the

reality of scientific and clinical evidence and bioethical

discussion negatively impacts the credibility of bioethics.

Furthermore, when bioethical discussions are not consis-

tent with scientific developments, the development and

uptake of beneficial therapies may be hindered. Irrelevant

or overblown bioethical debates also consume time better

devoted to more pressing and ethically difficult matters.

Finally, critics fear that ethicists engaged in speculation

may encourage the public to adopt an uncritical approach,

for example, through the favorable and overly sensational

media coverage cognitive enhancement has garnered

(Racine and Forlini 2010a, b; Wade et al., paper under

review). Unduly optimistic speculation may also present

the risk of arousing unrealistic or extraordinary expecta-

tions among different stakeholders, which have material

implications (i.e., the potential ‘‘squandering’’ of finite

resources on a technology or an issue that does not exist).

Thus criticisms of speculation may apply to those favoring

cognitive enhancement, as well as to critics of cognitive

enhancement.

On the other hand, some degree of speculation is

worthwhile because it enables the foresight of ethical

problems before a novel technology is introduced or dis-

seminated. In this sense, the practice of attempting to

forewarn by anticipating future scenarios may be valuable.

Roache (2008) claims that speculating about remote sce-

narios may help guide ethical reflection rather than detract

from it. Nonetheless, critics of anticipatory bioethics worry

that the identification of ultimately illusory ethical pitfalls

will dissuade researchers and investors from developing

important new treatments for real health problems (Henry

et al. 2007). There is perhaps also a risk of inaction in

failing to anticipate and resolve ethical concerns while

waiting for certainty or scientific consensus (Kolber 2008).

Jones et al. write a propos that, ‘‘[t]he challenge for bio-

ethicists is to determine whether they should devote their

attention to such extreme speculative possibilities, or to

more circumscribed speculations, or indeed whether it is

better to focus on existing issues, rather than those that are

merely possible’’ (Jones et al. 2011).

The language and conceptual frameworks used to

describe speculation embody normative positions that may

influence bioethical analysis. The act of predicting potential

outcomes can be captured with different nuances under the

labels of ‘‘forecasting’’, ‘‘foreshadowing’’, ‘‘envisioning’’,

‘‘imagining’’, ‘‘anticipating’’, ‘‘predicting’’, and more

explicitly ‘‘thought-experimenting’’, ‘‘promising’’ (Fortun

2005), ‘‘hypothetical possibilities’’, ‘‘speculative scenarios’’

(Roache 2008), and more negatively, ‘‘wishful thinking’’

(Oakley and Cocking 2005) and ‘‘scaremongering’’ (Carter

et al. 2009). Accordingly, different normative perspectives

have been presented in the literature with respect to spec-

ulation and its strengths and weaknesses based on specific

understandings of the role of bioethics and bioethicists in

relationship to ‘‘emerging’’ areas of science and technology.

In the specific case of cognitive enhancement, some con-

tend that the debate is based on ‘‘false assumptions’’ (Heinz

et al. 2012). This view raises the concern that distorted

evidence has clouded the understanding of the concrete

aspects of potentially harmful practices underlying perfor-

mance enhancement (e.g., non-medical use of stimulants or

do-it-yourself brain stimulation) and obfuscated the need

for genuine ethical and critical reflection.

Table 1 below outlines some of the main general per-

spectives about speculation. Future-oriented speculation is

a form of reasoning based on a set of unknowns, or

unverified social, empirical, and scientific knowledge about

the future. Anticipatory analysis is a type of speculative

approach that incorporates an effort to predict the impli-

cations of science and technology on society based on

possible future scenarios. In this respect, anticipatory

analysis incorporates potentially problematic assumptions

about science and technology. ‘‘Grounded speculation’’

adds constraints to the exercise based on the contributions

of scientific and social science knowledge. At the other end

of the spectrum, labels such as ‘‘wishful thinking’’ or

‘‘scaremongering’’ (Carter et al. 2009) draw attention to the

fallacies involved in the prediction of future scenarios.

The case of pharmaceutical cognitive enhancement is

particularly useful for drawing out how speculation about

science and technology (Table 1) intersects with contem-

porary bioethics. The drugs contending for the status of

‘‘cognitive enhancer’’ such as stimulants (e.g., methyl-

phenidate, dextroamphetamines) or acetylcholinesterase

inhibitors (e.g., donepezil) are already available and com-

monly used and prescribed by physicians. These medica-

tions are widely accepted internationally by health agencies

as effective for the treatment of disorders (Wolraich et al.

2011). The beneficial clinical effects of these drugs have

been documented in clinical trials published in peer

reviewed literature albeit the understanding of their phar-

macological mechanisms of action is incomplete (Iversen

2006). In some cases, initial studies of their efficacy to

enhance cognitive performance have been published (e.g.,

for meta-analyses of methylphenidate studies (Repantis

et al. 2010a) and for donepezil studies (Repantis et al.

2010b) but typically in small samples tested in artificial

settings, and without the benefit of double-blind random-

ized controlled trials (de Jongh et al. 2008). Prevalence of

use for enhancement has been documented mostly for

stimulants, often indirectly through broader surveys of

‘‘recreational uses’’ and typically in populations of limited

representativeness (e.g., specific North American college

Speculation and cognitive enhancement

123

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on

E. Racine et al.

123

campuses). Hence, the case of pharmacological cognitive

enhancement offers a mixture of existing and available

technology but discussed in a context marked by an

absence of clear and convincing evidence about efficacy

and prevalence of enhancement. The case of cognitive

enhancement is therefore a particularly interesting example

on which to base a critical appraisal of speculation. It

reflects a set of possible circumstances and social goals

while moving away from the purity of theoretical ideal-

types (Table 1) to bring attention to specific attributes of

scientific and social contexts. In fact, the complexity of the

debate on cognitive enhancement has given rise to a series

of assumptions, which we review briefly, related to: (1)

terminology; (2) scientific aspects; (3) sociological aspects;

and (4) normative aspects.

Assumptions about terminology and normative

frameworks used to describe the non-medical use

of stimulants

The terminology, definitions, and normative frameworks

used in bioethical discussions of cognitive enhancement

have carried diverse connotations, sometimes treating the

meaning of enhancement as self-evident and therefore

leaving it undefined. The diverse terminology has poten-

tially contributed to a mischaracterization of the non-

medical use of stimulants. For example, the terms ‘‘neu-

roenhancement,’’ ‘‘smart pills’’, and ‘‘cognitive enhancers’’

(Racine and Forlini 2010a, b) may poorly translate the

factual aspects of these practices and the normative fea-

tures they implicitly carry. The term ‘‘cognitive enhance-

ment,’’ suggests that certain pharmaceutical substances

work to enhance cognitive capacities generally and without

any tradeoffs (Racine and Forlini 2010a, b; Hall and Lucke

2010). The term also suggests the potential accomplish-

ment of a singular personal and social goal, namely to

‘‘enhance’’ or ‘‘become smarter’’. These enthusiastic

characterizations of pharmaceutical substances and social

practices could inadvertently influence ethical thinking

(Outram 2012), perpetuate or exacerbate misperceptions of

the practices and motivations, lead people to overestimate

the prevalence of the non-medical use of stimulants (Fer-

rari et al. 2012; Lucke et al. 2011) and create ethical blind

spots where misleading factual assumptions encourage an

uncritical stance (Racine and Forlini 2010a, b). Some have

contended that this portrayal of cognitive enhancement can

create forms of coercion in academic (e.g., peer pressure

created by the use of cognitive enhancers by fellow stu-

dents) and professional environments (e.g., pressure cre-

ated by the use of cognitive enhancers by colleagues, or

explicit pressures of supervisors to use enhancers) to per-

form at higher levels (Ferrari et al. 2012; Outram 2012).

Evidence from stakeholder research suggests that the

terminology and frames used to describe cognitive

enhancement could indeed have the consequence of

inducing fatalism and social acceptance of unproven

practices (Forlini and Racine 2009a, b; Forlini and Racine

2012; Wade et al., paper under review).2

Assumptions about scientific aspects such as efficacy

and safety of the non-medical use of stimulants

Several implicit assumptions about scientific aspects of

cognitive enhancement have been propagated in the liter-

ature despite the lack of supportive empirical evidence. For

example, it is widely assumed that certain pharmaceutical

substances optimize cognition (e.g., focus, concentration,

memory, and alertness) and that their use is safe. Even

among authors who acknowledge this lack of evidence,

there exists an assumption that evidence supporting their

efficacy and safety will eventually emerge if the right

studies can be done (Boot et al. 2011). Claims about the

safety and efficacy of stimulants in healthy individuals

have been partly constructed on the assumption that these

substances can improve cognitive performance in healthy

individuals just as they may do in cognitively impaired

individuals (Outram 2010b; Boot et al. 2011). However,

this generalization is problematic since the investigation of

pharmaceuticals in the context of illness cannot be gen-

eralized to non-medical use of stimulants in healthy indi-

viduals (Repantis et al. 2008, 2010a, b; Lucke et al. 2011).

Further, there are limitations to what existing study designs

can tell us about the efficacy and safety of the non-medical

use of stimulants because of the challenges of measuring,

assessing, and substantiating the efficacy of cognitive

enhancement in the absence of standardized tests for

enhancement effects (Lucke et al. 2011). For example,

claims about the effect of donepezil on a handful of aircraft

pilots have been heralded in the media and throughout

bioethics discourse as evidence of the cognitive enhance-

ment effect of donepezil in healthy individuals (Wade

et al., paper under review) in spite of explicit claims from

the original authors of the study to the contrary (Conne-

mann 2003). Moreover, it is difficult to know whether

reports suggesting the efficacy of performance enhancers

include individuals who are self-medicating an existing

2 Throughout debates about the non-medical use of stimulants, a

further complicating factor has been the evolving definition of the

term ‘‘cognitive enhancement’’. Ferrari et al. (2012) identify these

shifts in meaning by looking at the history of human enhancement:

‘‘the term ‘cognitive enhancement’ was originally used to describe the

treatment of disease-associated cognitive impairment…the meaning

of the term was subsequently broadened to encompass the use of

interventions for mild cognitive impairment (MCI) (…) More

recently ‘cognitive enhancement’ has been applied to interventions

in normal ageing processes and in ‘healthy’ people for non-medical

purposes’’ (Ferrari et al. 2012).

Speculation and cognitive enhancement

123

undiagnosed condition (Lucke et al. 2011; Outram 2012).

Finally, distinguishing enhancement effects from potential

placebo effects is difficult since user expectations and

confidence might increase cognitive capacities (Hall and

Lucke 2010) or elevate mood (Lucke et al. 2012). One

serious but underappreciated safety issue in this debate is

the overall addictive potential of stimulants (Heinz et al.

2012; Lucke et al. 2011; Ferrari et al. 2012), since these

‘‘substances necessarily modulate systems relevant for

learning and memory also implicated in drug addiction’’

(Heinz et al. 2012). Speculative discussions about cogni-

tive enhancement have ignored potentially serious safety

and efficacy concerns, sometimes even explicitly assuming

complete safety and effectiveness. The value of such

speculation is questionable if the underlying assumptions

are invalid.

Sociological assumptions about prevalence

and normalization

The literature on the non-medical use of prescription stim-

ulants frequently contains assumptions about the prevalence

of their use as well as increasing demand for stimulants

(Mohamed and Sahakian 2012). As well, assumptions con-

cerning moral acceptability, social desirability, and praise-

worthiness of cognitive enhancement have, in turn,

contributed to normalizing the issue (Ferrari et al. 2012;

Heinz et al. 2012; Lucke et al. 2011). Lucke et al. (2011)

identified at least three significant weaknesses of claims that

draw on studies about the widespread prevalence of stimu-

lant use. First, surveys conflate non-medical use and abuse

with use for the purpose of enhancement, thereby failing to

differentiate between the different ends towards which

stimulant drugs are used (e.g., undiagnosed ADHD). Sec-

ond, the studies cited do not support claims about the

widespread use of enhancement practices. Finally, the

results of surveys are not always accurately reported in the

current cognitive enhancement literature. Lucke et al. (2011)

suggest that the lack of information on the prevalence of

non-medical uses of stimulants requires that studies con-

tinue to examine and document the motivations surrounding

such behavior before making conclusions about the preva-

lence of cognitive enhancement practices.

Concomitant with the assumption that cognitive

enhancement is a widespread practice are the assumptions

of the social acceptability of taking medications without a

prescription and the moral praiseworthiness attributed to

the act of enhancement (Racine 2010). By overestimating

or exaggerating the extent to which enhancement is

undertaken, bioethical discussions could have implicitly

contributed to the argument that it is socially acceptable

because it is inevitable. Such an argument clearly overex-

tends what is known about non-prescription stimulant use

with respect to its moral acceptability, praiseworthiness,

and social desirability. In fact, the presumption may con-

flict with the little we do know, specifically students’

ambivalence about taking stimulants for the purposes of

enhancement (Forlini and Racine 2012; Franke et al. 2012).

The impact of erroneous claims about prevalence is not

unidirectional; overestimates may also prompt overly

negative reactions while underestimates could lead to lack

of due attention to the issue. Again here, unchecked

assumptions about prevalence and normalization, have

percolated into the debate and into the arguments of some

leading authors.

Normative assumptions about the need for ethical

reflection in the form of a ‘‘preparatory’’ or ‘‘anticipatory

ethics’’ and the call for regulatory guidelines

One final set of assumptions within bioethical discussions

on cognitive enhancement is the need for an ‘‘anticipatory

ethics,’’ ‘‘prospective ethics’’, ‘‘preparatory’’ or

‘‘upstream’’ ethics (Am 2011) and the need for regulatory

guidelines to respond to and manage requests by healthy

individuals for cognitive enhancement (Larriviere et al.

2009). This claim, identified in the literature as well as

policy discussions (Outram and Racine, 2011a, b), can be

boiled down to the call for a ‘‘prospective ethics in order to

avoid a gap occurring between ethical reflection…and the

state of the art in research and development’’ (Ferrari et al.

2012). Some bioethical discussions indicate that expecta-

tions surrounding the demand for cognitive enhancement

have set in motion policy discussions and regulatory

guidelines to help align social norms with public policy

(Farah 2011; Greely et al. 2008). However, if neither the

scientific nor sociological claims about cognitive

enhancement practices are substantiated by clear evidence,

the need to manage individual requests through ‘‘prospec-

tive ethics’’ and guiding regulatory frameworks can be

called into question (Ferrari et al. 2012). Lucke et al.

(2011) have captured the problem of unrealistic or exag-

gerated expectations under what they call the ‘‘neuroen-

hancement bubble’’, i.e., the effect of the exaggeration of

certain claims, the distortion of empirical evidence, and the

overall uncritical ethical analysis about cognitive

enhancement. Obviously the relationship between the nat-

ure of a scientific advance or a new health practice and the

need for anticipatory ethics is complex; the cognitive

enhancement debate cannot be dismissed as misdirected

ethics scholarship. However, this complexity has often

gone unacknowledged with some sweeping claims that

increasing or high prevalence necessarily calls for proac-

tive ethics discussion (with the equally debatable corollary

assumption that low prevalence would be a sufficient

condition to dismiss the debate).

E. Racine et al.

123

In the next section, we discuss how the different

assumptions could be better acknowledged in the cognitive

enhancement debate, and perhaps in other areas of bio-

ethics, in order to avoid some of the possible negative

pitfalls of speculation and to capitalize on the value of

proactive ethical approaches.

Methodological guideposts for informed and reflexive

speculation in bioethics

The ethical discussion about cognitive enhancement relies

on a mixture of factual evidence, especially about the

clinical uses of some pharmaceuticals, and limited evi-

dence about the efficacy and prevalence of non-medical use

for cognitive enhancement. In this context, speculation has

generated diverse assumptions (e.g., sociological, norma-

tive), which have shaped the debate. In reaction to the risks

of overextended and uncritical assumptions, some scholars

have offered a diversity of approaches to manage specu-

lation in scenarios characterized by uncertainty through

‘‘enhanced reflexivity,’’ skepticism and caution, better

evidence and use of evidence, ‘‘vision assessment,’’ and the

need to clarify and broaden the frame of the debate (Ferrari

et al. 2012; Forlini and Racine 2009a, b; Hall and Lucke

2010; Outram 2012; Racine and Forlini 2010a, b). Building

on these suggestions that empirical knowledge and self-

reflection be used to constrain and inform the debate on

cognitive enhancement, we propose three related method-

ological guideposts (see Fig. 1 for a summary of our

discussion).

Acknowledge assumptions more explicitly and identify

the value attributed to them

Speculation in ethics can be a very valuable tool. However,

the case of the non-medical use of stimulants shows that

ethicists, legal scholars and others could better identify the

assumptions or ‘‘hypotheticals’’ which have a determining

impact on the normative stances taken. To borrow the

language of casuistry (Jonsen 1995), notions such as effi-

cacy, prevalence, or social harms can amount to ‘‘circum-

stances’’ that ‘‘make the case’’ of cognitive enhancement.

Perhaps of greater importance is the need to recognize that

these circumstances are in some cases true variables or

hypotheticals, in the sense that different values can be

assigned to them and these values shape the global

appreciation of what is at stake and what is determined to

be the proper response. The use of assumptions and hy-

potheticals is well accepted in other domains of knowledge

which involve modeling decision-making and choices.

Economists, for example, using different models, do not

shy away from predictions about economic growth,

unemployment rates, or inflation but they are also asked to

make explicit the assumptions (or parameters) underlying

their models and their impact on the resulting predictions.

These assumptions can easily be overlooked but at very

least, they can be traced back, discussed, criticized, and

revised. To neglect or dismiss these underlying assump-

tions can lead to significant harms and misses the oppor-

tunity of analyzing them from an ethical standpoint

(Colander et al. 2009). Economists likely have more con-

ceptual and mathematical tools at their disposal than bio-

ethicists to pinpoint the assumptions they are making and

their impact on their scholarship. Given the amorphous and

implicit packaging of assumptions in bioethics, attempts to

make them clear and explicit would furnish useful prece-

dents that could help bioethics achieve additional rigor

particularly in relation to the use of assumptions within

speculation and modeling. An initial step could simply

consist in stating explicitly the assumptions (e.g., about

efficacy, prevalence) as well as the importance (or value)

assigned to them in the global ethical evaluation of cog-

nitive enhancement. Such clarifications would help distin-

guish disagreement about underlying factual assumptions

from disagreements about their normative evaluation.

Thus, disagreements could be better circumscribed and

their possible resolution better defined for further specific

inquiry. Avenues for further methodological progress

informed by other disciplines could be explored to build

more integrative and transparent use of assumptions in

bioethics scholarship.

Validate assumptions with interdisciplinary literature

Acknowledging the existence of assumptions is a first step

but we have also demonstrated that some assumptions in the

bioethics debate about cognitive enhancement have lacked a

sound empirical basis. Statements about prevalence have

been exaggerated and likewise claims about efficacy have

been reported inaccurately. Ferrari et al. (2012) observe that

‘‘ignorance of the empirical literature creates a bias effect

when it comes to formulating relevant ethical questions’’.

They state that ‘‘an improper account of empirical data

obtained in both experimental pharmacological research and

the social sciences restricts the narrative framework within

which the visions of pharmacological cognitive enhance-

ment are conceptualized, because it reifies it as an entity

despite the lack of evidence’’ (emphasis in the original).

Moreover, it functions to collapse a complex sometimes

contradictory phenomenon into a single framework of

understanding, i.e., ‘‘cognitive enhancement’’ (Outram

2012). A related recommendation in the literature is ‘‘cau-

tion and skepticism’’ regarding scientific and sociological

claims about cognitive enhancement practices and in

adopting the associated policy proposals and guidelines

Speculation and cognitive enhancement

123

(Hall and Lucke 2010; Lucke et al. 2012; Outram 2012;

Racine and Forlini 2010). Hall and Lucke (2010) have

argued that ‘‘[m]ore skepticism needs to be expressed about

neuroenhancement claims for pharmaceuticals and bioeth-

icists should be much more cautious in normalizing such

use by inflating estimates of its prevalence or making pro-

posals that will facilitate such use’’. Similarly, Outram

suggests exercising ‘‘cautious skepticism as to the future

implications of this practice’’ to avoid reification, misper-

ceptions, and hyperbole (Outram 2012). The validation of

assumptions about scientific aspects of cognitive enhance-

ment could have been pursued with greater energy and

commitment through the use of evidence from different

empirical disciplines and the adoption of higher standards

of rigor in searching for such evidence. These are directly

identifiable constraints to introduce within ethics reflection

about science and technology. In situations where factual

claims are hard to establish, intellectual honesty would

nevertheless call for clear and explicit acknowledgment of

the gaps.

Generally speaking, bioethics scholarship has long

stressed the need for sound factual claims in areas such as

clinical ethics and research ethics (Jonsen et al. 1998;

Beauchamp and Childress 2009). The use of empirical

research and the commitment to understanding factual

aspects of ethical situations has been claimed to be a

trademark of bioethics scholarship in comparison to other

approaches (Toulmin 1982; Racine 2008). Some approa-

ches in clinical ethics like casuistry have made of this a

formal first step of ethical analysis (Jonsen et al. 1998).

However, ethical analyses in themselves, and any resolu-

tion or action proposed by an ethical analysis, may involve

unknowns in terms of medical, legal, societal or ethical

outcomes. The challenge of predicting outcomes differs

greatly between the analysis of a clinical case (e.g., out-

comes and consequences of withdrawal of life support from

the point of view of clinicians and family members) and the

prediction of outcomes in a whole area of technological

development (e.g., pharmacological cognitive enhancers)

because of the vastly different scales of assumptions and

consequences involved. A clinical case may represent a

micro-context with great complexity but nevertheless some

immediately identifiable implications, with direct conse-

quences for individuals. But the nature of the assumptions

and unknowns involved in discussing the macro-context of

the nascent phenomenon of cognitive enhancement (e.g.,

prevalence, safety, efficacy, social acceptance) increase the

challenge of generating factual evidence to support the

claims and to inform transparently the normative stances

taken. Perhaps closest to the goal of anticipatory ethics and

Fig. 1 Increasing objectivity and reflexivity in speculation

E. Racine et al.

123

proactive ethical approaches is the field of health tech-

nology assessment where the ethical assessment of the

impact of a technology is undertaken. At this time, a few

methodological approaches have been proposed within this

field but they still fall short of reconciling the full com-

plexity of ethical analysis and its complex relationship to

factual assumptions (Van der Wilt et al. 2000). Further

theoretical and normative work could tease apart when and

to which extent, bioethicists should be expected to validate

factual claims implied in ethical analyses (e.g., carrying

empirical research themselves or relying on other

researchers’ work) and how they could do so (e.g., consult

primary literature or review papers; report explicitly the

level of evidence supporting different factual claims).

Adopt a broad perspective to support more

comprehensive reflection

Several problematic assumptions in the cognitive enhance-

ment debate point to a lack of perspective beyond contem-

porary societal and cultural contexts or preferred ethical

stances. A reflexive examination can be deployed as a cor-

rective to reveal and address latent biases, misguided

assumptions and gaps in the process of making certain claims

within the literature. Thus, reflexive practices introduce the

concept of an ‘‘ethics of doing ethics’’ because, as a practice,

they can correct biases and suggest questions about ethics

itself. We point to and discuss three relevant approaches

potentially supporting a more reflexive practice of bioethics.

Compare disciplinary frameworks

Although it has been suggested that the ethical discussion

of the non-medical use of stimulants is ‘‘reinventing the

bioethics wheel’’ (Parens and Johnston 2007) by those

active in early discussions about human genetic enhance-

ment, the case of cognitive enhancement shows that there

can be challenges when a phenomenon is uncritically

captured under an umbrella term like ‘‘enhancement,’’

which may carry assumptions from earlier bioethical

debates about other forms of enhancement. For example,

the data showing how ‘‘cognitive enhancement’’ became a

dominant frame in the bioethics literature point to a

problematic situation where other disciplines and per-

spectives (e.g., public health) were inadequately taken into

account (Forlini and Racine 2009a, b; Wade et al., paper

under review). In the epidemiological and public health

literature, more critical perspectives emphasized other

concerns such as addiction and public harm. This contrast

between public health and bioethics frameworks shows the

value of moving bioethics reflection away from its own

disciplinary comfort zones to consider the perspectives of

other fields or disciplines. Some bioethics discussions were

committed to an implicit ‘‘frame of reference,’’ which

defined the issues and nature of the topic and limited the

discussion and range of issues and solutions to be explored.

Hence, more explicit effort to research or imagine other

frames of references could be valuable to avoid biases in

ethics reflection (Racine and Forlini, 2010a, b). As Outram

(2012) suggests, ‘‘if we are to take into account the dif-

ferent frames by which to understand the non-medical use

of stimulants, we should adjust our ethical concerns

accordingly’’. The current enthusiastic framing of cognitive

enhancement may align with a technoscientific agenda and

could inappropriately constrain the discussion. Overall, a

general mindfulness of the language in ethical discussion

of cognitive enhancement (e.g., terms, frameworks) might

help avoid some early biases.

Consider historical knowledge

Looking at precedent social trends, events, and scholarship

can generally assist self-reflection (Racine and Illes 2006).

Relevant to the case of the enhancement use of stimulants,

previous work from Andrea Tone (2005) has shown that

anxiolytics (meprobomate in the 1950s and benzodiaze-

pines in the 1960s, 1970s, and 1980s) were used widely for

lifestyle purposes. Tone has invited further reflection on

how social context can shape new therapeutic paradigms in

psychiatry and, consequently, the need to take into account

a broad range of historical factors. By challenging the

suggestion of novelty implicit in the term ‘‘neuroen-

hancement,’’ Bell et al. (2012) highlight the lack of his-

torical perspective in bioethical discussions, and the

narrowness of bioethical perspectives that do not consider

the cycles of enthusiasm for drug use for enhancement

purposes throughout history. Lucke et al. (2011) similarly

situate the practice of cognitive enhancement within a

historical context: ‘‘[t]he use of stimulant drugs to enhance

human functioning is not a new phenomenon but arguably

a recent manifestation of a common cycle of enthusiasm

and disillusionment with the enhancement use of drugs

with stimulant effects’’.

Consulting the archives of the history of medicine,

specifically examining pharmacology and trends in treat-

ments could help ethical reflection to be more sensitive to

social factors that shape our ethical thinking about phar-

macological stimulants and other technologies. For exam-

ple, a historical perspective might shed light on the social

and cultural expectations surrounding technology and bring

additional insights to constrain speculation about the

present issue of cognitive enhancement, notably the impact

of social acceptance and normalization on ethical analyses

and resulting stances (Lucke et al. 2012). A related rec-

ommendation would be to make explicit social and tem-

poral contexts in which assumptions may be valid (Ragan

Speculation and cognitive enhancement

123

et al. 2013). In the case of the debate on cognitive

enhancement, the North American context of the initial

prevalence studies and the impact of this context on the

ensuing normative debate has often gone silent (Forlini and

Racine 2009a, b). Other societal and cultural contexts

could bring forth different ways of manifesting and

responding to ‘‘cognitive enhancement’’. To remedy the

fundamental biases related to context, contributors to

the debate would need to recognize that they themselves

‘‘are part of a specific culture and a specific society at a

concrete point of time in history. They also cannot break

out of the present, always shaping the futures they tell us

about on the basis of present knowledge, present estimates

of relevance, present values and present worldviews’’

(Ferrari et al. 2012). This would recognize the profound

embedding of ethical approaches in social context and its

impact on constitutive features of human psychology,

including ethical analyses (Dewey 1922).

Reflect on the development of normative approaches

Clearly, normative approaches to the non-medical use of

stimulants do not emerge by themselves but are an outcome

of an evolving and active process of thinking and analysis.

The task of ethics is partly to innovate and develop nor-

mative approaches to contemporary challenges (Illes and

Racine 2005). However, the immediate nature of the task

of bioethics can sometimes discount the implicit biases or

assumptions that can be carried forward as well as the

contingent and contextual nature of theoretical approaches

(Zoloth 2007), which have been described as ‘‘lenses’’ by

some feminist bioethics scholars (Sherwin 1999). Recently,

a shift from questions of the moral acceptability of stim-

ulant use to an examination of the social desirability of

enhancement has been identified (Ferrari et al. 2012).

Ferrari et al. call for an assessment of underlying visions,

noting that ‘‘[t]his implies distancing oneself from the

actual existence of certain desires in society and asking

which desires are based on good motives and how they are

attached to particular technological visions. Any genuine

ethical reflection on HE [human enhancement] technolo-

gies should explicitly acknowledge that it constitutes dis-

course on visions of technological development, rather than

concentrating on the novelty of ethical conflicts raised by

these visions’’ (Ferrari et al. 2012).

We might address problems of myopia and complacency

in ethical analysis by changing our assessments to consider

how norms are built into our framework of understanding

non-medical uses of stimulants at specific times and spaces.

Thus oscillating between different theoretical lenses could

generate a more comprehensive vision. In the case at hand,

it would become clearer that, ‘‘visions do not exist per se,

they are not discovered and they do not arise of their own

accord; they are ‘‘made’’’ since they are ‘‘deeply related to

our attitudes, knowledge, perceptions, values, world views

and interests of their authors and disseminators’’ (Ferrari

et al. 2012). Reflection on one’s normative stance is inti-

mately linked to self-reflection and an assessment of one’s

own biases and social positioning (Racine and Illes 2006)

and can thus help bioethicists take a more reflexive stance

in debates.

In the context of cognitive enhancement, where there

have been clear tensions between different normative

positions (notably between liberally-minded and more

conservatively-minded bioethics in the American context)

(Racine 2010), a few proposals have been put forward to

enrich theoretical lenses. These proposals have ranged

from recognizing the mutual terrain between opposed

normative frameworks or approaches (Parens 2005; Racine

2010) to the call for moral creativity beyond the battle lines

drawn by bioethics advocacy (Racine 2010). Parens has

proposed a dialogue between the creativity framework

(organized around the concept of self-transformation) and

the gratitude framework (organized around the concept of

lettings things be). He recommends acknowledging the

deeper assumptions (e.g., about human nature and tech-

nology) underlying these frameworks and recognizing how

single individuals may adhere to both frameworks (Parens

2005; Racine 2010). Racine has proposed that different

ethical evaluation criteria can be derived from opposed

normative stances, i.e., criteria of moral acceptability from

liberal positions and criteria of moral praiseworthiness

form conservative positions. These stances can then be

combined to yield a more comprehensive normative

approach (moderate liberalism) which builds on both

positions (Racine 2010). These two contributions by Parens

and Racine are steps in the direction of establishing broader

reflexive standpoints based on sometimes opposing nor-

mative views.

Although we have identified challenges in the use of

speculation in the cognitive enhancement debate, this paper

should not be interpreted as a dismissal of the contribution

of speculation in ethical thinking, but rather a framework to

enhance the relevance and quality of scholarship featuring

speculation. Speculation is an important part of ethical and

philosophical thinking and can yield valuable insight by

helping to expose socio-cultural values and help refocus

our ethical thinking on ‘‘maximizing what is most valu-

able’’ (Roache 2008). Speculation is also a strategy to

reduce technological determinism, by allowing ethical

thinking and response ahead of rather than at the heels of

emerging technologies. Speculative scenarios, when they

are understood as such, can yield insight into the present

and the future. In the context of our case study on cognitive

enhancement, most critiques of speculation have not been

wholesale arguments against the essence of anticipatory

E. Racine et al.

123

ethics or speculation as such. Rather, specific assumptions

have been identified where further objective analysis is

possible. For example, prevalence has been widely

described as ‘‘increasing,’’ including by one of the authors

of this paper (Racine 2010), although closer subsequent

examination of data showed conflicting perspectives.

Repeated and publically disseminated claims about matters

such as efficacy and safety are not benign. Bioethicists and

those involved in ethics debates become part of a social

construction process in which their claims contribute to

shaping and inflating expectations of the general public as

well as stakeholders like professional societies and gov-

ernmental agencies. ‘‘The media repetition of claims about

stimulant use has amplified the perceived extent of their

use beyond that which is indicated by closer examination

of the survey evidence’’ (Lucke et al. 2011). Hence it is

clear that a model of ‘‘constrained speculation’’ (see

Table 1) represents a promising middle-ground approach.

However, in hindsight, debatable assumptions appear

clearly in the discussion of cognitive performance

enhancers, but what is most challenging for the ethics

community, and perhaps more useful, is how to explicitly

identify and consider assumptions early in bioethics dis-

cussions and within clearer methodological guidelines. In

this paper, we have identified methodological suggestions

that should be further defined and explicitly employed.

There are some limitations to the approaches we propose

in this paper. First, the authors are from Commonwealth

countries (Canada and Australia) and represent limited

diversity in terms of cultural background. Second, we have

explored how speculation could be constrained and certain

types of assumptions be made more explicit but we realize

that more work and deliberation is needed in this area and

consider our paper to only provide some preliminary

reflections. Third, we have left aside for the purpose of this

paper the role that the media and other stakeholders have

played in the proliferation of assumptions about cognitive

enhancement (Forlini and Racine 2009a, b; Boot et al. 2011;

Partridge et al. 2011). We also did not focus on the socio-

logical or historical reasons why some of the assumptions

about the cognitive enhancement debate have made their

way into the academic debate. There are a range of alter-

native hypotheses which have not been explored in this

paper but may provide fruitful avenues of enquiry. These

may include the ‘‘incentive structure’’ relating to the career

progression of scholars (e.g., bioethicists being rewarded by

recognition following media attention, or achieving grant

funding for issues perceived to be of importance). Contrib-

utors to the debate about cognitive enhancement may also

lack formal bioethics training which then leads to a less

critical or scholarly treatment of the ethical issues that may

be involved. Another consideration is the tendency of jour-

nals to publish papers which are considered to be important,

leading to the temptation to overstate the significance of

issues. The investigation of these hypotheses would require

distinct research methodologies based on what has been

attempted in other areas of bioethics (Evans 2002).

Conclusion

In this paper, we have described the controversy over the

non-medical use of prescription drugs and underscored how

this case opened up the floor for reflection on the nature of

bioethics scholarship and the ‘‘ethics of doing ethics’’ about

emerging areas of science and technology. The case of non-

medical use of prescription stimulant is relevant because of

the availability of the technology (existing neuropharma-

ceuticals) and the discourse surrounding its repurposing as a

cognitive performance enhancer. We identified, based on

previous literature, distinctive sets of assumptions with

respect to terminology and framing, scientific aspects of the

non-medical use of stimulants, sociological assumptions as

well as assumptions about normative approaches. This

context set the stage for a discussion of how speculation

about the non-medical use of stimulants and science and

technology could be better informed. We proposed a

number of methodological procedures such as: (1)

acknowledging assumptions more explicitly; (2) validating

assumptions with interdisciplinary literature; and (3) taking

a broad perspective to support more comprehensive

reflection. We acknowledge our own reflection to be shaped

by our research goals and previous contributions and call for

greater awareness and willingness of the community of

scholars engaged in bioethics scholarship to partake in

exchanges on this topic.

Acknowledgments Support for this work comes from a catalyst

grant of the Canadian Institutes of Health Research (CIHR; Jennifer

Chandler, PI; Eric Racine co-PI), a University of Queensland Travel

Award for International Collaborative Research (Jayne Lucke), the

Canadian Institutes of Health Research (New Investigator Award,

Eric Racine) as well as the Fonds de recherche du Quebec—Sante

(Career Award, Eric Racine). We extend our thanks to members of

the Neuroethics Research Unit for feedback on a previous version of

this manuscript and to Ms. Allison Yan and Mr. John Aspler for

editorial support. Thanks to Brad Partridge who was a visiting

researcher at the Neuroethics Research Unit in 2012 for feedback on

the concept of this paper. Thanks also to Dr. Emily Bell and Dr.

Veljko Dubljevic for comments on a draft version of this paper.

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