Jamie Nicole LaBuzetta received her medical degree from UCSD, and is currently in the midst of her residency training at the Harvard-affiliated hospitals in Boston, USA. She is a neurology resident at the Partners program (Massachusetts General and Brigham and Women's, two of the Harvard-affiliated hospitals). Her current academic interests are in neurocritical care and neuroethics, and she was recently co-author of an article discussing ethical issues involved in consenting vulnerable patients for neuroscientific research.
Sahakian applied the “Page 99 Test” to their new book, Bad Moves: How decision making goes wrong, and the ethics of smart drugs, and reported the following:
Page 99 of Bad Moves finds us in the midst of discussing the benefits of using modafinil in healthy individuals. This captures a key issue in this book – should such ‘smart drugs’ be used by individuals who do not have neuropsychiatric disorders or brain injury? Modafinil is a ‘wakefulness-promoting agent’ for the treatment of “fatigue associated with narcolepsy, sleep apnoea, and shift-work sleep disorder”. Unlike traditional stimulants (e.g. methylphenidate or Ritalin), modafinil does not have demonstrable abuse potential which opens up the possibility of its widespread use by healthy individuals. The risk-benefit considerations may seem favourable for healthy individuals, although as yet no long term studies on the use of modafinil in healthy people have been conducted. On page 99, we see that modafinil improves decision-making and task enjoyment in healthy individuals as well as memory and attention in younger volunteers and spatial manipulation and mental flexibility in older volunteers. However, to fully understand the implications of having such ‘smart drugs’, we need to place it within the general framework of decision-making, which brings us back to the first few chapters. Decision-making can be purely rational, or ‘cold’, for example when choosing what ingredients to buy for supper. There are also ‘hot’ decisions that “have an emotional component or may involve weighing rewards and punishments”, for example when deciding whether to continue seeing your current partner or accept a date with another person. These “pathways interact in ways that allow our rational selves to be influenced by our emotions and vice versa. This critical interaction is necessary for normal life.” In pathological conditions, however, the balance is disrupted resulting in poor decision-making which can cause detrimental effects on daily living and important life choices. For example, in bipolar disorder, patients in the manic phase experience extreme and persistent euphoria which may lead to risky and bizarre behaviour such as, in one case, investing all their life savings on aquatic equipment intended to keep fish alive forever. So, are there drugs which can improve decision-making and cognition in neuropsychiatric disorders? Yes, there are and modafinil is one of them; for example, modafinil helps people with ADHD improve their performance on ‘cold’ decision-making tasks and enhances their ability to inhibit impulsive, unwanted behaviour. Back on page 99, we also explore the idea that the cognitive enhancing effects of modafinil might “have something to do with its primary function as a treatment for sleep disorders. Sleep is, after all, probably the most dramatic cognitive enhancer we know of.” But in cases where sleeping is a luxury and mental alertness is crucial, such as in sleep-deprived doctors or the military, modafinil and other ‘smart drugs’ might help to improve performance and reduce fatal errors. But why stop there? Perhaps drugs like modafinil can be used to improve cognition and performance in the general population as well, including the elderly. However, we need to stop and consider what the consequences will be if these drugs are readily available. Is it unfair, will people be coerced into using these drugs, and will we become a 24/7 society? These are crucial neuroethical issues that need to be discussed and we “require a well-informed and engaged public to participate in and shape the debate”.Learn more about Bad Moves at the Oxford University Press website.