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Please note that this is a pre-publication version. Do not cite this version but
please refer to the published chapter available at:
https://link.springer.com/chapter/10.1007/978-3-030-10677-5_2
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Shaping Children:
The Pursuit of Normalcy in Pediatric Cognitive Neuro-enhancement
Jenny Krutzinna
jenny.krutzinna@uib.no
Abstract Within the broad field of human enhancement, pediatric cognitive neuro-enhancement
appears to arouse particular interest. The increasing importance of cognitive capacities in our
contemporary and cultural context appears to be the main reason for the focus on cognition as the
preferred trait of enhancement, while the choice of pharmacological means is based on factors of
feasibility, accessibility and cost. While the ethical issues arising in the adult context have already
been extensively covered in the literature, pediatric neuro-enhancement brings with it additional
ethical challenges requiring further attention. Although there are numerous important ethical
considerations, the focus of this chapter is on the pursuit of normalcy as the goal in pediatric neuro-
enhancement. Parental attempts to shape children are not new and the resources available for them
to do so include widespread and mostly uncontroversial tools, such as education. The increasing
use of psychotropic drugs, however, reveals the significant impact of the concept of normalcy,
which has resulted in a trend to medicalise what used to be considered ‘normal’ (childhood)
behaviour. In this context, special challenges are posed by psychiatric disorders, where the familiar
treatment-enhancement distinction continues to be relied upon to justify interventions in children.
Drawing on the examples of attention deficit/hyperactivity disorder (ADHD) and autism spectrum
disorder (ASD), it will be argued that children are already being enhanced within psychiatric
practice and that this is incompatible with an understanding of disability under a mixed model.
1 Introduction
The idea of human enhancement is not new, but the rapid progress in biomedical technologies and
the continuing development in pharmacology make effective enhancement increasingly realistic
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and thorough ethical evaluation of interventions therefore urgent.1 While the type of enhancement
that is supposed to grant us superpowers is at present purely a matter of fiction, moderate
interventions are slowly appearing on the (medical) horizon. These include new technologies such
as genome editing (Ran et al. 2013), but also methods which have long been in use, such as
pharmacology (Bush 2006), now applied in the context of neuro-enhancement, which has been
described as ‘the use of prescription medication by healthy persons for the purpose of augmenting
normal cognitive or affective function’ (Graf et al. 2013).2
The enthusiasm for these scientific advances is accompanied by ethical concerns. Traditionally,
much of the debate has centred on the idea that the ethical permissibility of an intervention hinges
on whether or not it could be considered medical treatment. Although much has been written about
such a treatment/enhancement distinction,3 no conclusion has so far been reached and some
philosophers even argue that no morally relevant distinction can be drawn (Harris 2007). The
absence of an easy way to tell the good interventions from the bad is particularly problematic in
the context of children. Where autonomous adults are concerned, all things being equal,
enhancement raises no additional ethical issues with regard to the individual: Familiar ethical
concerns relating to individual autonomy, authenticity and personal identity arise, but these are not
special to enhancement and result whenever individual decision-making is concerned.4 The same
cannot be said for children, who can be described as particularly vulnerable due to their developing
autonomy and the fact that most decisions in the early stages of their lives are taken on their behalf
by others (mostly their parents), often with long-term, or even life-long, effects. This leads to a
dilemma, because on the one hand children need to be protected against undue interference with
their best interests, which might call for a cautious approach with regard to enhancement. To that
effect, it has been argued that there is no convincing evidence for the claim that pediatric cognitive
enhancement improves well-being (Krutzinna 2016), and the practice has also been found to be
against the best interests of children (Gaucher et al. 2013). On the other hand, the same best
interests make it difficult to reject enhancement interventions outright, because there might be
circumstances in which our moral obligation towards our children to prevent, mitigate or cure harm
or suffering, and our duty to pursue what is good for them, appears to require us to proceed with
an enhancement (Harris 2009). But how do we know when and to what extent it is morally right to
enhance? In addition to this moral question, the stakeholder perspective needs to be taken into
1 The use of potential performance enhancing drugs is not a new phenomenon: substances such as
amphetamines and cocaine have a long history of being used for this purpose: see Bell et al. (2012).
2 However, as will be discussed below, a lack of diagnostic clarity means that medication might be
administered even in the absence of a valid diagnosis, which would effectively amount to neuro-enhancement, or that
a diagnosis is only given to permit prescription, while in other cases diagnosis might be medically justified. For this
reason, too heavy reliance on ‘healthy person’ within the definition of neuro-enhancement is somewhat difficult.
3 There is an abundance of literature on this topic; however, a detailed review of the treatment / enhancement
debate is beyond the scope of this chapter. For further information on the debate see Harris (2007).
4 Full consideration of these issues is beyond the scope of this Chapter, which has as its focus the pediatric
context. For an interdisciplinary overview, see Hildt and Franke (2013). In addition, questions of distributive justice
and fairness are relevant on a collective level.
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account, which has been found to place more emphasis on degree and context than on an absolute
right or wrong binary (Fitz et al. 2014).
So far, much of the ethical discussion surrounding pediatric enhancement has focused on the means
of enhancing. Although not universally accepted as enhancement at all, conventional methods, such
as education, training, and diet and exercise, appear much less controversial, while new
technologies and pharmacological interventions raise scepticism or are rejected categorically
(Habermas 2003; President's Council on Bioethics and Kass 2003). This approach, however, fails
to solve the aforementioned dilemma of knowing when pediatric enhancement is morally justified,
or even advisable. To bring out the real ethical issues an alternative approach needs to be taken,
namely that of evaluating the ends pursued. It is not sufficient for a conclusion of ethical
permissibility to demonstrate that there is nothing inherently wrong with the chosen enhancement
method, but rather it needs to be demonstrated that the goal which is being pursued by a particular
enhancement is one that is morally acceptable.5 Education can be as morally despicable as the
administration of drugs if it is done with an unethical goal in mind, such as indoctrination. What
matters in the present context are the ends pursued by cognitive neuro-enhancement, that is, the
goal parents have in mind when they opt for enhancement of their children. This, it will be argued
below, is frequently framed in terms of normalcy to justify interventions to modify child behaviour.
2 The Idea of Normalcy
The idea of normalcy dates to the nineteenth century, when Sir Frances Galton first introduced his
statistical model and the accompanying Bell curve (Davis 1995). This point can be said to mark
the beginning of medicalization where that which was not ‘normal’ suddenly had to be cured or
treated. Today, this idea has developed so far that previously accepted character traits have in some
cases become fully-fledged psychiatric disorders. One such example is depression: In Aristotle’s
time some people were described as melancholic characters, while the same trait is now too often
seen as a medical condition warranting intervention (Davis 2014).6 The current edition of the
Diagnostic and Statistical Manual (DSM-V) issued by the American Psychiatric Association
defines the qualifying amount of time for major depressive disorder as two weeks, although
realistically it is difficult to conceive of a shorter period of sadness for many life-changing events
(Davis 2014).7 This idealization of a happy constitution puts enormous pressure on people to self-
improve, and has led to the flooding of bookstores with self-help advice and continues to provide
a steady source of income to life coaches and therapists (Haybron 2008), but it is important to
5 It might be objected that it seems bizarre that if there is nothing morally wrong with an enhancement method,
that it should not be permissible. The reasons for this will be addressed in the next section.
6 This is not to argue that something only becomes a medical condition once it is labelled as such, but it
illustrates how culture and context affect what is perceived as a condition warranting intervention.
7 It is important to note that sadness is but one of the diagnostic criteria for major depressive disorder. Others
include diminished interest or pleasure in activities and feelings of worthlessness or guilt.
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remember that what counts as normal or is seen as a disorder changes over time, as a historical
review of the diagnostic manuals reveals (Davis 2014).
Neurodiversity, as an opposing concept, embraces neurological differences rather than seeing them
as some form of malfunction. Subscribers to this view often express a preference for identity-first
rather than person-first language (Sequenzia 2016; Sparrow 2005),8 endorsing neuroatypicality as
an identity rather than a defect or disability (Solomon 25 May 2008). Although there is no
consensus on this issue even within the autism spectrum disorder (ASD) community, it is a view
worth noting when thinking about the ethics of pediatric neuro-enhancement, especially since
similar movements are emerging in other communities (e.g. The Icarus Project, which involves
persons typically classed as mentally ill, and whose vision it is ‘to overcome the limitations of a
world determined to label, categorize, and sort human behaviour’). It is thus necessary to carefully
consider whether treatment, as far as it is even available, is appropriate in all circumstances. This
will entail an analysis of the pursued ends, which ought to be both realistic and in the best interests
of the children, not merely in those of their carers or the general public.
3 Why Ends Matter
As argued above, thorough ethical analysis requires an evaluation of both ends and means. It is not
sufficient justification to claim that the means of enhancement are ethical, because ultimately the
ethical permissibility of any intervention hinges on which ends are being pursued. Morally
speaking, the administration of drugs to a child for pain relief is not equivalent to the administration
of drugs for purposes of tranquilization in the absence of actual pain but purely for the convenience
of parenting. In both cases, the means – the giving of drugs – are the same, but the ends being
pursued are different and only in the former case can it be confidently argued that the drug giving
is in the best interests of the child. The latter case is far more contentious and requires more
information to be presented before a conclusion on the ethical permissibility can be reached. Where
it turns out that the ends pursued are entirely unethical, the intervention also becomes unethical. In
the present example, if the tranquilizing drugs are given to the child because the parents struggle
with the child’s lively character, this constitutes an infringement of the right to respect for persons,
and could pose a threat to the innocence of childhood (Singh and Wessely 2015). The legitimacy
of the goal partly depends on the subjective experience of the child in question; as such, it is not
possible to give a generalized ethical judgment for certain types of interventions, because there is
no objective standard to be applied. If, for instance, the tranquilizing drugs are administered to this
child because of a risk of self-harm, the intervention could be morally permissible.9
8 This means a preference to be referred to as an ‘Autistic’ rather than as ‘a person with autism.’ A similar
preference exists in part of the Deaf community.
9 Whether or not it will be deemed morally permissible will depend on the facts of the case, and would have
to be determined through a careful weighing of risks and benefits, as well as consideration of the preferences of the
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This means that wherever non-autonomous persons, such as children, are concerned, their best
interests need to be critically assessed, and the ends pursued will determine the appropriateness of
any means chosen to reach those ends. It is important to note here that ‘low-tech’ means are not
per se ethically better – even education can be used for morally wrong goals.10 It is therefore crucial
to closely review the reasons for a decision in favor of any kind of pediatric neuro-enhancement,
which leads to the question of underlying motives.
4 Motives and Reasons
Enhancement features strongly in both popular and scientific media across the world, especially
the idea of cognitive enhancement, i.e. the improvement of cognitive capacities, including general
intelligence, memory, and the ability to concentrate, by pharmacological and genetic means
(Partridge et al. 2011; Wade et al. 2014). One reason for the special interest in cognitive
enhancement might be a belief in the great instrumental value of intelligence in a competitive
society, where productivity and achievement appear to be valued above all else. In this time and
place, unusual or inconvenient behavior in children tends to become quickly medicalized, with
drug treatment being the preferred means of address by some parents and doctors. The existing
limitations to the effectiveness of cognitive enhancement appear to leave the enthusiasm for
possible interventions unhampered, and discussions about potential risks and benefits are
increasing. Besides genetics, where scientific success in permanently improving cognitive capacity
is slower than many had hoped (Yong 2013), neuro-enhancement by means of pharmacological
interventions is receiving increasing attention (Partridge et al. 2011) and is feared to become
widespread despite current evidence indicating that prevalence rates are low (Lucke et al. 2011).
One of the reasons for this is that access is relatively easy and inexpensive – unlike for instance
genetic means, which are still in their infancy in terms of effectiveness and are also likely to be
much more financially burdensome.
Motives underlying a parental wish to enhance a child can range from the treatment of underlying
conditions, the improvement of specific capacities for their own sake (intrinsic value), to ‘giving
an edge’11 and the achievement of certain (parental) goals. In the latter case, medical diagnosis can
become a way of concealing parental desires to raise high-achieving, socially-conforming children,
and medical professionals might become accessories in parents’ ambitious plans when they grant
access to medications for healthy children in the hope of cognitively enhancing effects. The case
of American physician Dr. Anderson, who admitted to prescribing psychoactive drugs to children
in the absence of an actual diagnosis of attention deficit/hyperactivity disorder (ADHD) to
child in as far as this is feasible. In addition, relational aspects matter: for example, where the parents and other family
members are harmed as a result of the child’s behaviour, intervention might become justifiable.
10 Arguably, if education were (mis)used in such a way, it would no longer be education in the proper meaning
of the term.
11 That is, for instance, to confer a competitive advantage to the child in comparison to his or her peers.
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compensate for bad schooling, might appear an extreme and exceptional case (Schwarz 9 October
2012), but this approach has recently been endorsed by some academics as an option meriting
serious consideration (Ray 2016). Although this same idea has been rejected by other scholars
(Sattler and Singh 2016), it demonstrates that the generality of symptoms and the resulting
difficulty of correctly diagnosing psychiatric conditions, combined with a lack of understanding of
their underlying causes, pose special challenges to ethics. These will now be briefly outlined,
followed by a case study to emphasize their practical relevance.
5 Challenges of Psychiatric Disorders
Psychiatric disorders tend to be ‘invisible’, in the sense that their diagnosis relies on clinical
assessment of behavioral symptoms, which in the case of children are difficult to distinguish from
normal childhood behaviors (Singh 2008). These disorders are notdiscrete entities, and the current
diagnostic manuals, DSM-V and the World Health Organization’s International Statistical
Classification of Diseases and Related Health Problems (ICD-10), offer definitions that are best
described as ‘a grab bag of symptoms that could easily also comprise many other diagnostic
categories’ (Davis 2014). This leads to obvious diagnostic difficulties, where both over- and
underdiagnosis become likely, as has been the case with ADHD (Singh and Wessely 2015). It is
thus with good reason that the diagnostic validity of disorders such as ADHD continues to come
under social and ethical scrutiny (Singh 2008).
5.1 Models of Disability
The lack of diagnostic clarity makes it difficult to determine the status of many psychiatric
spectrum disorders, including ADHD and ASD. Whether they are considered to be disabilities,
impairments or simply ‘inconveniences’ depends on individual, cultural and temporal factors.
Rather than acknowledging this uncertainty however, the diagnostic manuals suggest authority and
give the impression of clarity (Davis 2014). In addition, they rely heavily on a medical model to
describe disease, which by itself is problematic not least because the United Nations Convention
on the Rights of Persons with Disabilities has advocated for a social model. The difference between
the two models lies in the perspective taken with regard to disability. Whilst the medical model
views disability as based on factors lying within the person, the social model draws a distinction
between impairments of a person and the resulting disability arising through society’s response to
those impairments. Many disability rights advocates subscribe to the social model and reject a
‘broken brain’ theory in the case of psychiatric disorders, appealing instead to the concept of
neurodiversity, according to which atypical neurological development is simply a normal human
difference (Jaarsma and Welin 2012). They fear that medicalization of naturally-occurring
neurological differences is used to justify intervention with undesirable traits and behaviors. This
infringes the right to respect of persons with neurological differences, and they argue that non-
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medical solutions to disabling life circumstances would be more appropriate than treating the
affected individual as intrinsically disabled. An important shortcoming of this view is its failure to
appreciate the fact that at least some psychiatric conditions are associated with real pain and
suffering, making the treatment of the underlying cause justifiable without necessarily constituting
a threat to respect for the disabled person. Rather than relying on a purely social model of disability,
it is thus more convincing to argue for a combined approach (Shakespeare 2013). This can also be
seen from the case of ASD, which illustrates that the worries expressed by disability rights
advocates are somewhat justified, as those affected by ASD have a long history of having to fight
for their fundamental human rights and against coercive treatment (Silberman 2015).
5.2 Autism Spectrum Disorder (ASD)
Rather than there being merely an underlying medical issue that needs to be addressed, a ‘complex
cultural and historical scenario’ (Davis 2014) presents itself in the case of psychiatric disorders,
especially affective disorders. ASD is a suitable example because it is not unlike ADHD or other
psychiatric disorders in that there are many overlapping diagnostic criteria, although ICD-10
currently precludes a dual-diagnosis (Gargaro et al. 2011). While both used to be considered
childhood disorders, adult diagnoses are increasingly being made, which in the case of ASD has
led to very vocal communities raising awareness for the needs and interests of autistic individuals.
This is yet to occur for ADHD to the same extent, although an adult ADHD community is
emerging. At present, however, the VOICES project is the first of its kind in including affected
individuals in the debate, still focuses exclusively on children with ADHD (Singh 2012).
Like ADHD, diagnoses for ASD are on the rise (Singh 2008; Silberman 2015) and the same gender-
based issues arise with regard to over- and underdiagnosis (Gould and Ashton-Smith 2011). In
some cases, treatment attempts haven even involved the same psychoactive drugs, such as deanol
(Silberman 2015). The cause of ASD is still poorly understood. Fortunately, previously popular
but unscientific theories about the origins of the disorder, such as the idea of so-called ‘refrigerator
mothers’ (Silberman 2015), have now been largely abandoned. This means, however, that
attempting treatment of the symptoms is the only option for parents of an autistic child. Over the
last decades, questionable therapies and dubious drug regimens have all been marketed to desperate
parents as ameliorating ASD, with little or no scientifically proven success. A substance containing
sodium chlorite, similar to industrial strength bleach, has been sold as “Miracle Mineral
Supplement” (MMS) to parents as cure for their children’s autism, often with devastating health
effects (Ryan 13 July 2016).
Another popular treatment choice is Applied Behavior Analysis (ABA), which in its most extreme
form recommends 40 hours of Early Intensive Behavioral Interventions (EIBI) to teach children to
abstain from their ‘autistic behavior’, such as the self-stimulating behavior known as ‘stimming’,
which consists in the repetition of movements and / or sounds. The focus of ABA is on ‘socially
significant behavior’, and is criticized by many, not least for its definition of success as behaving
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like a neurotypical, i.e. a non-autistic, person. Amy Sequenzia, a non-speaking Autistic, and
spokeswoman for the Autistic Self-Advocacy Network, argues that this is unethical and abusive
(Parker 20 March 2015). It is difficult to conclude on the effectiveness of ABA as treatment for
ASD, because most of the evidence is anecdotal. However, even if empirical evidence were readily
available, effectiveness alone would not suffice to answer questions of ethics conclusively and
some of the reports from previous ABA-patients urge us to be skeptical of this highly lucrative yet
scientifically unproven therapy, which Canadian autism researcher Michelle Dawson describes as
reminiscent of ‘the past and current unethical treatment of other atypical human beings’.12 This
demonstrates that focusing merely on the results of the intervention clearly disrespects the
autonomy of the individuals affected and raises important issues about the contemporary
idealisation of the ‘normal’ in our culture.
The preceding discussion has highlighted the importance of thorough ethical reflection on pediatric
neuro-enhancement, which will impact further research and regulation of current and future neuro-
enhancers. Most, if not all, biomedical technologies and interventions raise ethical concerns,
whether they are based on bioethical principles (Beauchamp and Childress 2001), the right to an
open future (Feinberg 1980), or on human rights (United Nations General Assembly 1999). In the
case of pediatric neuro-enhancement, ethical concerns can be broadly divided into three categories:
concerns about (future) autonomy, concerns about designing children, and concerns about
balancing public and private interests.13 Although these are somewhat interrelated, individual
analysis is helpful to tease out the fundamental ethical values at stake. This is crucial in the process
of reaching moral (and legal) conclusions about the permissibility of pediatric neuro-enhancement,
and in developing an appropriate regulatory framework for such interventions, which in the light
of scientific progress and societal demand appear unavoidable.
6 Key Ethical Issues arising from Cognitive Neuro-enhancement
As mentioned above, increases in diagnoses have occurred for several neurological disorders, such
as ADHD and ASD, although the reason for this increase is not certain. While this might simply
be due to more experienced physicians and better diagnostic methods, it is equally possible that
social and cultural changes such as a shift towards more cognition-focused educational and work
settings are responsible for the higher prevalence rates. Another alternative might be environmental
causes, pollution or pathogens. Whatever the reason, since it implies that more children and young
12 Dawson herself was diagnosed with ASD as an adult and has continuously challenged the scientific
foundation of ABA-based autism interventions. She has also challenged the medical necessity of such an intervention
in the Supreme Court of Canada in the case of Auton v. British Columbia.
13 Other ethical concerns are those based on justice and/or fairness, which typically arise whenever resources
are limited or access is restricted. Since this applies to most if not all health-related interventions, they are excluded in
the present context for brevity’s sake and the focus is instead on those types of concerns that arise in the specific
context of pediatric neuro-enhancement. This is not to imply, however, that justice and fairness are less important in
the overall ethical debate.
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persons will likely become targets of treatment in one form or another, it is crucial to afford
sufficient protection to the interests of these children, and to provide parents, teachers, and health
care professionals with practical guidance on how to best address the challenges encountered.
Where possible, deferral to the future when the children themselves can become involved in the
decision-making process, such as whether to take psychoactive drugs, should be considered.
Engaging young persons as early as possible, listening to their preferences and understanding their
sense of self-identity is an important step towards respecting their (developing) autonomy.
Research with adults has shown self-identity to be an important issue in the diagnosis and treatment
of psychiatric illnesses, which suggest that it might be useful to repeat these studies in the context
of children to discover their perspective (Corrigan and Watson 2002; Solomon 2013).
6.1 Autonomy
Arguments against enhancing children are often framed in terms of autonomy. One of the most
prominent approaches is Joel Feinberg’s right to an open future argument (Feinberg 1980).
Although Feinberg was not writing about enhancement, he was concerned with protecting the
future autonomy and self-fulfillment of children, which might be forfeited if the wrong decisions
are made on their behalf. According to him, ‘wrong’ decisions are those that are of a limiting nature
with regard to future self-fulfillment and autonomy. This means that decisions leading to a
perceived overall benefit for a child could be considered wrong whenever they limit the child’s
capacity for making his or her own choices as an autonomous adult, because this would be an
infringement of the child’s right to an open future.
Whilst Feinberg’s approach has significant intuitive appeal, the open future argument raises
important questions in practice. It is not entirely clear, for instance, how this right can be reconciled
with parental autonomy in raising children, given that most (if not all) decisions parents make with
regard to their children’s upbringing have an effect on their future lives. It would appear to imply
that parents ought to adopt a precautionary approach, and refrain from making any decisions that
might have too great an impact on the type of person their child will become. Given that it is
practically impossible to know the precise effect even small parenting decisions have on a child’s
developing autonomy, this appears unrealistic and too burdensome for parents, who need to deal
with everyday issues and cannot spend too much time pondering on potential consequences every
time they need to make a decision with regard to their child. In addition, it is quite likely that
parents opting for any kind of enhancement do so precisely because they hope to advance the
openness of the child’s future. Finally, in the present context of pediatric neuro-enhancement, it is
important to be aware of the risk of ‘biomedical enhancement exceptionalism’ (Buchanan 2011),
because pharmacological means of enhancement are not intrinsically different from ‘ordinary’
educational or parental interventions in a morally significant way. All things being equal, parental
autonomy in raising children ought to be respected and decisions be left to parents. Interference is
only justified where the child’s welfare is actually at risk. In that regard, pediatric neuro-
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enhancement, assuming it is generally safe and effective, is unlikely to pose a greater threat to a
child’s right to an open future than other parental choices.
6.2 Designing Children
It is entirely natural for parents to have hopes for their children, but even working from a ‘good
parent’ hypothesis, that is, the assumption that parents are genuinely concerned about their
children’s best interests and well-being, the issue of parental expectations can be somewhat of a
tightrope walk. Parenting never happens in isolation, with parents being continuously subjected to
significant and difficult-to-escape outside pressures, which are partly culturally determined, as well
as internal pressures. In much of the Western world, there appears to be increasing instrumental
value in great cognitive capacities, because of the shift towards more brain-based work away from
manual labour and the fact that being a productive member of the working population is crucial for
one’s social status within a society. There might thus be a danger that parents will succumb to
pressures and attempt to shape their children in a way that makes them best fit into society, even if
this means resort to neuro-enhancement drugs.
This is problematic for two reasons: First of all, there is a threat posed to the child’s healthy
development by the parental expectations, which come with a decision to medicate a child, and a
more general risk of instrumentalizing children. Second, there is a risk of sacrificing the healthy
parent-child relationship.
With regard to the former, where prescription drugs are administered for neuro-enhancement
purposes, it is likely that parental expectations will be raised at least to some extent or there would
be little reason for parents to agree to the medication in the first place. Although healthy
development will allow children to grow into autonomous adults, children are not equivalent to
small adults. Their development is a fragile enterprise and their future autonomy can be seriously
threatened, not only by harmful decisions but also by excessive expectations and pressure put on
the child (Ablard and Parker 1997). The effects of this can last a lifetime, and might lead to
significant (mental) health problems (Freeman 2013). The risks appear greatest where despite
pharmacological intervention, children for one reason or another fail to perform as expected or
even show signs of ‘reduced functioning’ (as might be the case, for instance, due to negative side
effects to treatment, or a psychologically-based refusal to perform).
Furthermore, there is a risk of compromising a healthy parent-child relationship, in which parents
are responsible for the education and healthy development of their child. This might occur for
instance when pharmacological means are used as a way to bypass educational efforts in raising
children to achieve the goal of ‘proper functioning’ of the child. Administering neuro-enhancing
drugs might become the shortcut to manipulate a child’s behaviour where there is a failure to
comply with norms and expectations, rather than the more complicated process of explaining and
convincing a child of the importance of such norms, values and beliefs. The complex task of
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education is seemingly simplified, making negotiations with the child superfluous. As a result, the
child’s right to participate in her own development will be infringed (United Nations General
Assembly 1999) and she will be deprived of the ability to negotiate her own identity (Stein et al.
2011), and the safe harbor that is the parent-child relationship can be put at risk as a result of the
parents ‘siding’ with health care professionals or teachers, conveying the message that the child is
somehow ‘not right’.
6.3 Private and Public Interests
While there are obvious private interests, such as parents’ wish to ensure the health and well-being
of their child, the public interest at play should not be underestimated. Successful treatment, or
even cure, of a disorder will have a positive effect on the individual’s productivity, and implies a
potential long-term reduction in health care costs and educational expenditure. Given the prospects
of benefits of any enhancement not only for individuals but also for society at large (and thus the
state), there is a need to protect children from being instrumentalized for ‘the greater good’.
Potential gains in societal productivity are significant, which means that the incentive for neuro-
enhancement in children is very strong for the state (Buchanan 2008). In addition, the influence of
the pharmaceutical industry is not to be underestimated: psychiatric disorders are a lucrative
business, and parents desperately trying to improve their children’s condition make easy targets.
Intense political and economic interests bear on the formation and relevance of diagnostic
categories, such as those found within the DSM, which can be seen from the transparency research
showing that the rate of panel members with strong ties to the pharmaceutical industry continues
to be extremely high (Cosgrove and Krimsky 2012). As a result, psychiatric diagnoses might
become more prevalent in order to allow parents to enhance their children, while at the same time
increasing profits of private corporations.
The combination of conflicting interests of the parties involved and the general vulnerability of
children make thorough ethical analysis in combination with empirical research absolutely critical.
Many aspects of neuro-enhancement are still under-researched, calling for independent
interdisciplinary research followed by proper scrutiny of the results. This should include
engagement of affected individuals to the extent possible, before professional medical, educational
or parental guidance and a suitable legal framework can be developed. It will be important to strike
the right balance between allowing and encouraging research to be undertaken to understand not
only the conditions but also the effects of any interventions, while at the same time protecting
vulnerable children’s fundamental developmental rights.
7 Conclusion
For an enhancement intervention to be deemed morally permissible, it is not sufficient that the
means are not ethically wrong – the ends matter too. Therefore, a thorough ethical analysis of
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neuro-enhancement necessarily involves an evaluation of the goals which are being pursued.
Although these tend to be framed in general terms, such as the increase of a child’s well-being, a
closer look reveals reliance on the notion of normalcy to justify interventions. To that effect, the
risk of what could be called a ‘diagnostic creep’14 in psychiatry is illustrated by ASD, which
demonstrates the intrinsic problems of many psychiatric disorders, most notably their lack of
diagnostic clarity and the disagreement as to whether neuroatypicality really ought to be
medicalized and treated (and if so, how). Even a brief analysis of three broad categories of crucial
ethical concerns arising from pediatric neuro-enhancement highlights the difficulties in reaching a
moral conclusion about the regulation of such interventions. For two reasons prohibition is not a
feasible option: First, given the globalised world we live in and the steadily expanding cross-border
medical travel industry, those desiring access and with the appropriate financial means would
simply get access elsewhere; and second, despite the abovementioned inherent risks, there are also
benefits to be obtained from at least some neuro-enhancement interventions; the ethical problems
arise from misuse rather than use. The appropriate response would thus not be to radically constrain
research and development efforts, but rather to sensitise the public, health care professionals,
teachers and parents to the ethical issues at play, and to develop a suitable regulatory framework
capable of allowing interventions to proceed where this is in the best interests of the child whilst at
the same time protecting children’s emerging autonomy and their fundamental developmental
rights.
14 I am grateful to an anonymous reviewer for this suggestion.
13
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