we all know this isa huge exper. human beings are stepping up to be potentially poisoned.

if there's anything that you can get that's gonna give you an edge over your fellow classmates, you're gonna take it. to throw all of that normalcy away in order to take some memory-enhancing or intelligence-enhancing drug seems to me crazy. we don't have the wisdom to know what memories we want to remember and what memories we want to forget. what happens if, in reality, there is nothing wrong with this drug except you can memorize a verse of shakespeare in one evening instead of a week? there are basic neuroscience principles and basic rules. and if you play with these rules, you play with fire. announcer: the situations are hypothetical, but the dilemmas are real. from the boardroom to the bedroom, from the courtroom to the classroom, men and women put their values to the test as they struggle with the kinds of decisions we face everyday. fred friendly seminars presents "ethics in america." this hour, "a better brain: the ethics of neuro-enhancement."

announcer #2: funding for this program is provided by annenberg media. announcer: "ethics in america" is a presentation of the fred friendly seminars at the columbia university graduate school of journalism. welcome, everybody, to this very special science assembly here at albert einstein high school. we've invited some people who have done studies and work on the brain, to present to us here and to tell us about some of the exciting things that haven gone on in the world of medicine. a graduate of albert einstein high school who now works for a company called hope pharmaceuticals has come to deliver some remarks about the project she's working on. it's a drug called "alerta" that hope has developed. alerta is a drug that allows you to go without sleep for long periods of time.

but a woman in the back row is sitting and listening to this graduate-- her name is maria-- and she hears alerta and a light goes off in her brain. because it reminds her of this second job that she's taken at a law firm where one of the associates at the law firm said, "you know a great way, maria, to work longer and harder is to take this stuff alerta." so she goes to your office, dr. satel, and says, "you know, i really could use this alerta stuff." do you write her a prescription? that's a good question. i don't know if i would. because as clinicians, we treat diseases, and this is not a clinical disease. this is a manipulation that this woman, understandably, would like to have. personally, though, i believe she should have access to it. and maybe we should have psychiatrists like we have plastic surgeons, the kind of psychiatrist who does the cosmetic psychopharmacology.

hold on for a second. i mean, this drug was developed for narcolepsy - which is a devastating disorder, of course. - right. and it shows very limited side effects. and you happen to know maria. maria is a responsible adult who has this period of time that she really needs this help. she's asking you for the prescription. what do you do? i might go ahead and do it especially for a time-limited period if the drug were well-tested and if she understood the risks, and i would monitor her frequently. sandel: i don't understand. there is no disease, - is that right? - that's right. she has no disease. well, the thing that worries me in this case, there's no medical need. the need arises, or the apparent need arises because of some pressure, apparently, to work a second job or pressures to fit into a certain kind of set of competitive pressures, whether it's kids in school, or taking a test, or working longer at the law firm.

and those-- i think the danger is that if we start to use drugs to fit people more neatly and comfortably into the pressures created by competitive society, we're less likely to critically reflect on whether that's the way we want to organize our society in the first place. that's my worry. art caplan, is there a fundamental difference between granting a prescription for narcolepsy and granting a prescription for someone who, for good responsible reasons, wants to stay awake to help her family? i think there's a difference, but it doesn't make the person who wants to enhance, or improve, or do a better job, necessarily wrong to seek that help. you might say, in the case of maria, she doesn't have a disease, but she does have symptoms-- she's getting tired. she's worried she might put somebody else at risk on the job if she goes to sleep.

she's worried she might have a car accident if she drives home tired. so she's got problems. and michael's right. it may be a tough world where you have to have a second job, but it's the world she lives in. and she can wait for michael to fix it. but right now, she's still got to go home and she's driving home late at night. and she needs to stay awake. so i'm thinking, "yeah, i'm writing this prescription whether it's a disease or not, she's got an issue that she faces, and the pill may help." you've said it's okay to prescribe for narcolepsy. you've said its okay, probably, to prescribe for maria. does that include also the law partners who want to bill lots and lots of hours by staying up late and make partner? perhaps. although, there, the fear is that if we keep them up and let them make partner, imagine the damage they'll do to society. - ( all laugh ) - only if they're trial lawyers. the other aspect of giving it to the lawyers to improve their performance, or to the athletes to improve their performance, or to the students to improve their performance on the s.a.t.

is that it puts pressure on everybody else in that competitive field to also take that substance. we value in many areas how we got to that goal or success. so in athletics, it's not just, you know, the number of homeruns you hit, but how you developed that skill to hit it. what, dr. hurlbut, is going on here? she's getting a drug for something that's not a disease. is this treatment? what is it? how should we think about this? well, actually as this has been proceeding, i've been thinking what if maria had said, "my tenth grader at albert einstein high school has serious issues with his homework and needs to be able to stay up longer." would the same rationale hold here? and i think we'd all have a little pause on that. i think we have to be very careful not to convert all of life's challenges or circumstances into medical problems. there are obviously certain circumstances we use

compounds that alter our behavior, such as caffeine. last night, the person sitting next to me got a little enhanced on their red wine. but-- and we wouldn't say that was a medical treatment, exactly. the thing is you have to realize is that biology is a very complex balance. and the physicians in this room will know very well that there's no such thing as a drug that does one thing. look at the list of adverse reactions on any pharmaceutical that gets prescribed for you. we don't use drugs casually. that's why they're regulated. when they're seen to be safe, they sort of make their way out. but even then, i think it's an experiment on your life and probably an invasion of your life. lawler: now, just tweak the story just a little bit: maria's boss comes by and says, "you're doing a pretty good job. but if you had this drug, you'd be doing a great job." and she says, "no." and the guy says-- her boss says,

"i'll get someone then who will do this." and in all these cases of some kids start to take the drug to stay up to get their homework done, then the pressure would be on everyone. so what seems to be a matter of free choice, can actually produce this indirect tyrannical pressure. hockenberry: but is that in play with maria now do you think? - lawler: i think so. - how? i did change the story a bit in so far as i said, "you're doing an okay job. but you could do a great job if you were enhanced in this way." but she's probably thinking that very thing, "i'm doing a good job. but i can do a great job if i'm enhanced in this way. my job will be more secure. i'll get a raise." and this might be her free choice in a competitive marketplace. but once this is available freely, then the pressure would be on for everyone to do it. and the unenhanced will be at such a serious disadvantage that, in fact, they're being tyrannized over it. - but your looking at-- - that's always been the case. exactly. you're looking at a situation in which what society wants is changing. there's a general change in society as to what's acceptable and what's not acceptable. the whole idea that somebody would show up at work and say,

"jeez, i'm really doing a great job today because i took my alerta." would not have been acceptable 25 years ago. hockenberry: maria got through her two-job episode. time passed, and now maria is keeping herself awake at night for a very different reason-- it's about her eight-year-old daughter camilla. she has no friends. kids call her "weirdo." she doesn't know what she does that's weird. she eats lunch and is on the playground by herself every single day. a short while back, maria was told by the counselor at her school that there is a medicine she might consider taking, a medicine called "amikind" that was developed to help people with asperger syndrome, and it's been shown to be effective in helping people to pick up social cues. now, dr. abramson, where might the counselor get this idea

that this drug is possibly an appropriate treatment or alternative for camilla here? so much of what the counselor knows about this drug is coming directly from the drug companies. so what we think we know may come from the association for socially isolated girls. but much of the funding for that association may come from the manufacturer of this drug, and the manufacturer may well have put on a seminar for guidance counselors about helping children like this. and the guidance counselor is dedicated to his or her job, and wants to do the best for the child. dr. satel, how would you handle this issue? i think it's perfectly fine that the teacher discusses it with the parent, doesn't demand. for all we know there's another kid in the class on this drug who's improved markedly, so the teacher actually has some observational experience with this. what's your view of what dr. abramson has said about the way the drug companies disseminate information?

satel: i know there are some problems. on the other hand, a lot of patients find this advertising very instructive. this is a hook that a patient can use to approach his physician who is not bound often just by the literature. they have their own experience with these drugs to draw on. abramson: most of our medical studies are now funded privately by the drug industry, and the odds are five times greater that the commercially- funded research will find that the sponsor's drug is the treatment of choice, than when the research is done on the same drugs - by non-commercial sponsors-- - satel: in psychiatry if someone comes in for depression, it's not as though i'm going to be mislead into prescribing the wrong drug. there are so many frontline drugs we can choose from. and then we often change along the way, and titrate and see how the patient responds. it's very empirical, and hands on, and-- caplan: john, before they resolve the evidence base for this poor little kid,

i wanted to know if anybody's gonna give a discussion to the mom and the child about somebody like bill gates. who might have had these problems in the playgrounds. and apparently, he is a person who is not great at picking up social cues, and people have wondered, "is that somebody who--" hockenberry: yeah, he's really had a miserable time. exactly, he's had a tough go. so even though i am not averse to trying out drugs when needed, i might think we'd want to have a little discussion about people who've been a little more socially awkward at eight and went on to do things. how does a drug like this change our perception of people like camilla? lawler: there's more tyranny there because we see a socially awkward kid who doesn't pick up social cues. you say, "well, poor kid." but there's some good sides to having that kind of personality. but once there's a chemical remedy for this, then there's sort of a duty to give it to the kid

to make the kid pick up the cues better, do better in school, have more friends, and all of that. hockenberry: what's wrong with that? because in fact, the kid might be better off being slow with the social cues. the kid might have a right to his or her moods. lynch: your phrase as "tyranny"-- what the background deep concern is that we're gonna build a society that's incredibly homogenous with this kind of thing. and homogenous in the sense of, "let's physically rearrange the way people look. they're too short to play baseball, let's give this kid h.g.h.-- - human growth hormone." - lynch: growth hormone. what do you wind up with at the end of the day? and there's a terrible risk to society of reducing its diversity, just as in a biological population. when you reduce the diversity, you go extinct. tully: i don't think it's necessarily true that we'll even reduce diversity by introducing these kinds of drugs to society. and i like your notion about tyranny, but the extrapolation of it is that technology is tyranny.

if i'm a plains indian in the 1500s trying to run down a buffalo for food, and my buddy goes speeding by on a horse, that's tyranny. scalia: has anybody asked whether camilla is unhappy? diller: yeah, camilla's unhappy. we've heard from her parents. her parents want her to be-- maybe she likes being all alone on the playground. let's assume she does! hockenberry: let's find out. should it be up to her parents to give her some drugs... - of course. - ...to make her like everybody else? - diller: what's wrong with unhappiness? - huh? - what's wrong with unhappiness? - that's another question. - because, again-- - ( laughs ) it used to be part of the human condition, unhappiness. but i think in the last 40 or 50 years there's been a shift away from older values. and if we have a child who's feeling badly, the parents feel badly. and they come to me, this kid may be minimally impaired in my view, but he's not feeling good, his self-esteem is down, and they want a treatment. the evidence that self-esteem or self-image really matter

is scant to non-existent, and most of that evidence comes from, you know, interviewing ceos, artists, and criminals. - and they all have bad childhoods. - ( all laugh ) hockenberry: let's pose a question here. martha, if you could be maria. you have gotten a prescription for amikind. you're holding it in your hand. you haven't decided what to do, so you turn to your family members-- and you have a large family-- and many people who are willing to guide you. let's begin with your brother-in-law, dr. lawler. and your brother, art caplan. he looks more like an uncle but... good. in any case, ask them for guidance. okay. well, listen guys. camilla has really had a hard year at school. and if it was just a matter of keeping her cheery, keeping her happy, sparing her any disappointment in life, you know, i'd go along with some of these friends of mine

who are telling me happiness is not the be all, end all. that's not the most important thing about somebody's childhood. but i just have the feeling, seeing her when she comes home at the end of the day. that it's more than just... she's not having fun. she's really missing out on you know, the world of people, and friendships, and connections. what do you think? is it worth trying to do something to her brain to open up that world of, you know, human relationships to her? i've three things: one, have you tried everything else first? number two, have you really studied up on this drug? and number three, if this decision is made, do not take pressure from the teachers, and the bureaucrats, and so forth. it's your right to have your kid be an unhappy pain in the ass in class

if you think in the long run that's best. yeah. no, i'll tell you, i don't feel that this is for the teacher's convenience or anything. i mean, i really-- i feel like she's missing something in her life. but, you know... ( sighs ) well, you know, maria, i never liked him much anyway. ( all laugh ) remember we had that discussion about home schooling? and you said you wanted her to go to meet kids and become social with others. so i think your values are very important here. ashe probably gets some sense from you that you're worried about this. when i talk to her, she is unhappy. but i'm not sure she's desperately unhappy. i'm not sure she's not picking up some of your anxiety about how she is at school that bothers her. i've been up on the-- let me say that's an excellent point. we agree on that. yeah, i'll see you at thanksgiving. anyway... but i think ultimately if you and her agree that she can't take it anymore,

i'd give her the pill for a little while and see what happens. but i want to make sure she's not picking it up... - yeah it's hard to-- - ...from you. it's hard to disentangle my wishes for her as a parent and what she really wants and needs. gazzaniga: maria, we've got a problem here. - you're the problem. - who invited him to this family? you're the problem. it's not your daughter, it's you. you've been compulsively managing this child for the last eight years. you've looked, you fold the laundry, you do everything. - you cook, you-- - tully: you soccer mom you. - ( laughter ) - gazzaniga: you are enormously controlling. it's not the child. back off. - you take the pill. - ( laughter ) tully: but look, parents have been making these decisions for their kids forever. if we wanna expand the conversation to this, it's not just about drugs. i think the problem's with maria. and this is the thing that's always overlooked in these child-parent interactions, anorexia nervosa and all the rest--

diller: i think that's unfair to maria, very much so. and i'm the one prescribing those medicines every day. there are a lot of societal forces pressuring maria, but the idea that somehow this is just bothering maria, not bothering the kid is a bit unfair. hockenberry: michael sandel, what would you do if you were in maria's shoes? and talk to maria. when you say it's shyness that you're gonna cure with the drug, is it shyness in the sense of not having an anchor person's bland fluency? - ( laughter ) - or is it-- - hockenberry: that was unfair. - because... - i'm really hurt. - no no, i didn't mean it... - no offense meant. - no no. no, i wasn't thinking of you. no. no no, you're as-- john said... let's talk to maria. and what would you do? i insist on it. i'm not talking about the trenchant influency of john over here.

is it a case of the-- something that we now worry about in the name of shyness? because we live in a society where the standards of fluency, and competence, and efficiency, and competitiveness have so been ratcheted up that we have to ask ourselves, "are we really treating a disability here? or are we acting out of a set of pressures?" that without our even noticing it really, have led us to cast certain ways of being in the world as pathologies when maybe they're not. maybe it's the society that's giving rise to these pathologies. - not our kids. - farah: you know what as camilla's mom-- - which is it? - as camilla's mom, i don't care. - i don't care whether she has a diagnosis... - sandel: fair enough. ...that you can find in the diagnostic manual, or whether she's just-- she's not happy.

- sandel: right. - but the fact that she's suffering... ...missing out on opportunities-- that's what i care about. if there's a way to help her, i want to do that. and you know what, if by my doing that ratchets things up a little bit for the other kids in the world, - right. - i don't care. she's my kid. right right. although, i would worry a little bit. i would worry a little bit what she thinks as you're deliberating about her condition and taking her to the doctor about her condition. whichever way you go, now she-- doesn't she think that she has some kind of condition? but you know, it's no worse when you took that son of yours who was having trouble in fifth grade, you know, when you took him to the tutoring service? that may have given him a little bit of a self concept of, you know, somebody who isn't quite up to it on their own, and she has that too. but, you know, i think you're right about that. but precisely because i worry about this.

and i even worry that excessive competitive pressures led me to take him to the tutoring service that he didn't really need. i worried a little bit what he thought i thought of him when i took him there, even though it wasn't a drug, even though it was low tech. hockenberry: josh, you used to baby sit for camilla a while back. a lot of worry here among the older folks. any guidance? you're certainly somebody who the family trusts. well, you know, i drove her to her ballet lessons occasionally, and to her speech lessons, and to her structured play times. and i've seen that she's actually suffering and that there's a real, tangible unhappiness here. and i hear these abstract concerns about how this will change the nature of your relationship with her, how it might affect the kind of society we would live in if every kid was prescribed these drugs. but i see immediately before my eyes, a tangible unhappiness. and i think you have an obligation to do what you can as a parent to resolve that.

hockenberry: that would mean... that would mean getting these drugs, yeah. - one thing i-- - well, let's turn just for one second to wise uncle nino, who often when there is a lack of clarity in the family, - you, maria, have turned to him. - ( laughter ) maria, i am glad you have finally come to your old uncle nino to get advice. frankly, the way i would approach this is to ask the question whether camilla has a disease. is it something that has to be medicinally treated? if it is not a disease, i would let it be. there are people who are more social, there are people who are less social. there are people who are smarter, there are people who are less smart. i would not change the world by giving everyone who is on the bottom end of all of these different characteristics drugs. that's my advice as a wise old man

who has seen much of the world pass in front of him. all right, maria certainly has plenty of information to make her decision, and we will leave her to make her decision out of our sight. and move to a different scene. welcome to strivers university, everyone. you may have heard of it. john strivers, of course, was that revolutionary era figure who is forever immortalized for giving ben franklin - those keys to tie on the kite... - ( laughter ) ...that ended up in the famous picture. josh, what do you think the relationship between neuropharmacology and some of these students might be in the setting that i've described? first of all, you're walking in through a pall of smoke. but once you get in, you might find students saying, "well, there are certain drugs out there that a few of my friends on the hall are-- have been prescribed, like adderall or maybe it's alerta. - they have more of the--" - hockenberry: for what?

oh, for their a.d.h.d., or their-- whatever disability they've convinced they psychiatrist they have. and what do they use the drugs for? well, some of them are using them legitimately to treat this disability. some of them are using them once a week, the night before the big exam. some of them are using them also on saturday night, so they can stay out later and party. hockenberry: you've had a little experience with this, right? right, i wrote an article last year where i actually took adderall for a week to see how it would affect me as a writer. - this "article..." - ( laughter ) describe your experience. well, you know, it's hard to say whether there was a placebo effect here, but i felt like i was an immensely more productive writer. i produced more pages. i felt more clear-headed. that urge to check your e-mail every five minutes just like vanished. but at the same time i also felt maybe a little bit less creative, like i was thinking with blinders on.

and in the end i decided this was not a drug i would want to take every day of my life. so i would take this drug if i was at strivers to study for an exam, to stay up late, to help myself get through a mid-term week. is that the idea? sure, absolutely. in fact, if you look at some of these studies, it's about one in five college students are doing this. dr. farah, you're a teacher at strivers university. what impression do you have of what's going on that, you know, josh is describing here? well, when i talk to my students about this, none of them actually use these drugs themselves, - but they all know people who do. - ( laughter ) and just judging from what they tell me about the people that they know who use them, i would say it is quite common, you know, 20% sounds right to me. and my first reaction was, "oh my god, this is terrible-- drug use, illegal, you know, irresponsible." but i have to say, you know, the students that i hear about from my students,

they seem to be using it in a pretty responsible way. they have various tools to help them with their work, new features of their laptops, their blackberries, et cetera, and at term paper and exam time, they have this other tool. dr. abramson, what do we know about the long term effects of the use of these drugs on otherwise perfectly normal kids? that's a wonderful question. because we don't know about the long term effects. the studies have not been done. so clearly these drugs can benefit some children, adolescents, adults in the short-term. there's no question. but we don't know the long term effects of these drugs. we do know from basic principals. we do know that certain classes of drugs used over a long period of time are very likely to be dangerous. they're very likely to create changes in the brain that are gonna be detrimental further in life. and certainly stimulants fall into that category.

that's the danger, i think, to what's going on in the colleges. if it's this widespread, and it certainly is, this is a very very bad idea. what we're talking about here, the kids at striver say, is actually the old days. because today, now, there's something new on campus-- rememberall. just developed. and this is a spectacular drug. i mean, this is something that was developed for alzheimer's. but in the context of strivers university, all of a sudden, you don't have to take adderall. you don't have to stay up for the exam. you just study with rememberall and wow, the effects are incredible! what's likely to be the usage rate, josh, at strivers now that we're in the rememberall era? if there's anything that you can get that's gonna give you an edge over your fellow classmates, you're gonna take it. provided it's safe, a lot of people will think about taking it. and you? me, i don't know. i think i would try it, possibly. it depends also whether it's illegal.