Research support for this article was provided by the Investigative Fund of The Nation Institute.

II. Changing Brains

Or what if we had other powers? What if we could sleep less, rejuvenate our aging brains, rebound quickly from emotional trauma, improve our memories, regulate our moods, enhance our sexual response? Increasingly, we do have those powers, thanks to neurological interventions that range from psychopharmaceuticals to surgery to brain-machine interfaces.

Currently, the most famous neuro-interventions are SSRIs (the class of antidepressants that includes Prozac and Zoloft) and the anti-ADD medication Ritalin. But rivals are on the way. Consider, for instance, the drug modafinil. Marketed in the United States as Provigil, modafinil was developed to treat narcolepsy, but doctors and patients quickly realized that it enabled healthy people to stay awake for far longer than normal--anecdotally, for more than three days. "Suddenly, narcoleptics had a lot of friends," Martha Farah says with a laugh.

Who can deny the allure of modafinil? Not surgeons, one suspects, or long-haul truck drivers, or military personnel on multiday missions--or, for that matter, journalists on deadline. Modafinil's intended use, like that of Prozac and Ritalin before it, is dwarfed by its nonmedical potential. Because many therapies that help the sick can also benefit the healthy, this slippery slope from treatment to enhancement is a defining feature of the neurotechnology landscape. Thus Alzheimer's drugs could improve normal memory, brain-machine interfaces for Lou Gehrig's disease patients could be adapted for Air Force pilots and modafinil could make workaholics of us all.

Here, however, are some other salient details about modafinil: There are no long-term studies of its effects, its mechanism remains mysterious and the role of sleep in regulating human health is largely unknown. These facts point to the most basic ethical concern about neurotechnologies--to wit, their safety.

Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics, is a champion of neuroenhancement, but he acknowledges that "technologically, we can't even build a dam that doesn't break." Theoretically, safety issues could be handled by careful oversight, but history does not inspire optimism. To illustrate the point in a debate with Caplan, University of Minnesota bioethicist Carl Elliot cited "three of the most commercially successful medical enhancements of recent years": SSRIs, hormone replacement therapy and the diet drug Fen-Phen. All three were FDA-approved and widely used before the public learned that the first are associated with suicide; the second with stroke, pulmonary emboli and breast cancer; and the third with heart disease and hypertension.

Nor does history suggest that we will establish careful rules about when, why and by whom neurotechnologies may be used. "The most relevant forerunner may be reproductive technologies, and what's happened there is an absolute lack of oversight," Caplan says. "We've got no rules about counseling, about describing the risks of side effects. We have no agreement about who can use these services. The whole thing has been treated as a Wild West free market."

That frontier free-market mentality does not bode well for the poor. Given that we do not guarantee basic healthcare in this country or fully fund such low-tech equalizing efforts as Head Start, it's tough to imagine that we will insure access to neuroenhancements for those who can't afford them. If enhancement becomes widespread, then, the advantages it confers will only exacerbate existing disparities in education and employment.

Caplan is quick to point out that this injustice lies with society, not with science. Plenty of other "technologies" magnify disparities, from private schools to test-prep courses. But neuroenhancement could make it not merely difficult but biologically impossible for the poor to compete with the wealthy. It is worth asking, as Elliot has, whether we want to widen the gap by commodifying basic human traits and inviting the pharmaceutical industry to market them.

Alongside questions about equitable access to neuroenhancers are equally grave concerns about the freedom not to use them. Already, some schools refuse to let "difficult" students attend class unless they take ADD medicine. The Defense Department's Advanced Research Projects Agency funds research on modafinil because "eliminating the need for sleep while maintaining a high level of both cognitive and physical performance...will create a fundamental change in war fighting." Certain nonmilitary employees could also be required or coerced into using neuroenhancements; imagine, for instance, a drug that improves concentration among air-traffic controllers. And then there is the thought experiment I posed earlier: Should the law be allowed to mandate neurological interventions that decrease violence? Current case law suggests that the answer could be yes; courts have ruled that if the state can administer the death penalty, it can also intervene in ways that stop short of death (e.g., chemical castration). As Farah points out, these uses of neurotechnologies threaten to violate a kind of freedom that, to date, is barely adumbrated within the law--the freedom to have our own personalities and control our inner lives.

For most of us, though, the freedom not to enhance our brains won't be jeopardized by the military or the courts but by a society obsessed with competition and self-improvement. As we have learned from professional sports, it is exceedingly difficult to make thoughtful choices about enhancement technologies once they are widely used. When I asked Caplan how we might protect people from pressure to alter their neurochemistry, he said, "I think you have to build niches for respecting those people, like how we deal with the Amish. They have opted away from common technologies, but we accommodate them, and they get to ride their little buggies around." Considering that the Amish make up less than 0.0003 percent of the population, and that cars are perhaps the most common and coveted technology in the country, I asked whether the analogy was apt. He thought it was: "I predict that many of these interventions will be like caffeine, which is an omnipresent enhancer. I'm not sure anybody will have a giant implant in their head anytime soon, but as for the pill that lets you stay awake longer, or the this-helps-me-focus pill, or the memory booster--I think it's crazy not to start anticipating that."

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