How to Prescribe Smart Drugs to Children Ethically

Ilina Singh and colleagues are said argue that the use of drugs such as Ritalin among young people is becoming so common that family doctors should be able to prescribe them as study aids to school pupils aged under 18 in arecent article in the Guardian. While the Guardian article rather cherry-picks from the range of Singh’s arguments in her original article, I have made similar arguments to those in the Guardian broadly supporting cognitive enhancement myself.

However, one might ask whether the prescription of enhancement for young children who are incapable of consenting for themselves raises unique issues. The limits to should  be:

1. Safety – the drug should be safe enough and benefits clearly outweigh the harms
2. Harm to others – the drug should not cause the child to harm others, by for example, increasing violent behavior
3. Distributive justice – the delivery of the drug should not use up limited societal resources unfairly, for example, by consuming resources which would do more good if directed towards educational strategies
4. The parent’s choices are based on a plausible conception of well-being and a better life for the child
5. The effects are consistent with development of autonomy in child and a reasonable range of future life plans

These last two limits are important.  It makes for a higher standard of “proof” that an intervention will be an enhancement because the parents are making choices for their child, not themselves. The critical question to ask is: would the change be better for the individual? Is it better for the individual to to be relaxed but failing and lazy or hardworking, successful and tense?  We require good data on the effects on normal children and we won’t get this until we do proper double blind controlled trials on normal children. These questions are difficult to answer.  While we might let adults choose to be take the risks themselves, and decide whether upsides outweigh the downsides, we should not let parents choose interventions which are harmful to their children, like denying them blood transfusions or cochlear implants. If smart drugs are as safe and effective as they appear to be, paradoxically, it may be harmful not to prescribe. There might be a moral obligation to provide smart drugs just as there is one to provide a cochlear implant to a deaf child.
There will be cases where some intervention is plausibly in a child’s interests: increased empathy with other people, better capacity to understand oneself and the world around, or improved memory.  One quality is especially associated with socioeconomic success and staying out of prison: impulse control.  If it were possible to correct poor impulse control, we should correct it.  Whether we should remove impulsiveness altogether is another question.

Joel Feinberg has described a child’s right to an open future.  An open future is one in which a child a reasonable range of possible lives to choose from and an opportunity to choose what kind of person to be. That is, to develop autonomy. Some  critics of enhancement have argued that genetic interventions are inconsistent with a child’s right to an open future.   Far from restricting a child’s future, however, some biological interventions may increase the possible futures or at least their quality.  It is hard to see how improved memory or empathy would restrict a child’s future.  Many worthwhile possibilities would be open.  But is true that parental choices should not restrict the development of autonomy or reasonable range of possible futures open to a child. In general, fewer enhancements will be permitted in children than in adult.  Some interventions, however, may still be clearly enhancements for our children and so just like vaccinations or other preventative health care.

Sometimes, you hear the argument that in the case of kids, decisions should be deferred until the child is old enough to decide for itself. This is right when waiting has not costs. But in the case of education, the horse may have bolted by the time the child is 16 or older, old enough to decide. That cost has to be weighed into the equation. Some choices cannot be reversed.

The key, as I have said, is to make these choices with a wide conception of what is plausibly good for the child and good data on the effects on smart drugs on that well-being. This requires a societal dialogue on what is a good life and the willingness to do scientific research on normal children in large numbers. The cost of not doing this is likely to be large numbers of children getting these drugs on the “grey market” with unknown and potentially serious side-effects. Or short-sighted, nervous policy makers banning them, with the potential huge opportunity costs.

Time to do some proper research.

Comments

[Stephan Schleim]

While I welcome your explication of the limitations, I call into question your conclusion to call for more proper research. In the first place, this call is somewhat void, as nobody so far seems to have been able to give necessary and sufficient conditions of what "proper" research on cognitive enhancement would be, i.e. a conceptualization of research designs and methodology which in the end would guarantee (or at least make it likely) that this research actually answers the questions which are *relevant* to individual's and society's life and policy decisions instead of *significant* findings which ultimately raise more questions than they answer. I would like to point to the fact that scientists and clinicians are still debating on the long-term effects of methylphenidate (e.g. Ritalin, Concerta and other brand names) consumption, although this drug is known and prescribed now since more than six decades. While some bioethicists call it "safe enough" (e.g. J. Harris, British Medical J 338, p. 1532-3), other authorities issue black label warnings on severe physical and psychical side effects, particularly in children (e.g. Medication Guide for Concerta by the Food and Drugs Administration of the USA issued in 2007).
Secondly, whether there is indeed a continuous increase in stimulant consumption can be questioned (and has been questioned in the current issue of BioSocieties, 5(1), 153-156). It appears that methylphenidate and amphetamine consumption now reached the levels of the late 1960s.