NHMRC Australia Fellowship 569738 award to Professor Wayne Hall 2009-2013 postprint
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Partridge B., Lucke J., Hall W. A comparison of attitudes toward cognitive enhancement and
legalized doping in sport in a community sample of Australian adults. American Journal of Bioethics -
Primary Research 2012; 3: 81-86.
Abstract
Background: This article compares public attitudes toward the use of prescription drugs for cognitive
enhancement with the use of performance enhancing drugs in sport. We explore attitudes toward the
acceptability of both practices; the extent to which familiarity with cognitive enhancement is related
to its perceived acceptability; and relationships between the acceptability of cognitive enhancement
and legalized doping in sport. Methods: A survey was administered through a computer-assisted
telephone interviewing system to members of the Australian general public aged 18–101 years in the
state of Queensland. Results: Of 1,265 participants, 7% agreed that cognitive enhancement is
acceptable; 2.4% of the total sample said they had taken prescription drugs to enhance their
concentration or alertness in the absence of a diagnosed disorder, and a further 8% said they knew
someone who had done so. These participants were twice as likely to think cognitive enhancement
was acceptable. Only 3.6% of participants agreed that people who play professional sport should be
allowed to use performance-enhancing drugs if they wanted to. Participants who found cognitive
enhancement acceptable were 9.5 times more likely to agree with legalized doping. Conclusions:
Policies that facilitated the use of prescription drugs by healthy people for cognitive enhancement or
permitted performance-enhancing drugs in sport would be at odds with the attitudes of the vast
majority of our participants. Furthermore, our findings do not support media claims that the use of
prescription drugs for cognitive enhancement is widespread in all sectors of society.
Keywords
cognitive enhancement, doping, methylphenidate, neuroenhancement, performance-enhancing drugs,
public attitudes, public opinion
The archetypal example of nonmedical use of prescription drugs by healthy people for “cognitive
enhancement” is the university student who buys prescription stimulants (e.g., Ritalin or Adderall)
from a friend because she wants to improve her normal level of concentration or achievement while
studying (Greely et al. 2008). Such behavior has been compared to the use of performance-enhancing
drugs (PEDs) in sport. Similar concerns have been expressed about the two activities regarding: (1)
users gaining an unfair competitive advantage; (2) competitive pressure coercing nonusers to engage
in the practice; (3) the inauthenticity of drug-enhanced performances; (4) the potential benefits to the
“enhanced” individual; (5) the health risks of using prescription drugs for nonmedical purposes; and
(6) the effectiveness of the relevant regulatory systems in discouraging such use (see, e.g., Cakic
2009; Kayser et al. 2005; Kayser and Smith 2008; Lucke et al. 2011b; Partridge 2010).
The nonmedical use of prescription drugs by healthy people for cognitive enhancement and the use of
PEDs in sport are both prohibited behaviors. Since the inception of the World Anti-Doping Agency
(WADA) in 1999—globally formalizing a prohibitive stance toward the use of PEDs in sport—
expenditures on eradicating “doping” in sport (e.g., drug testing of athletes) have increased
enormously. Cognitive enhancement per se is not regulated explicitly, but in most developed countries
there is a prescription system for acquiring putatively enhancing drugs, such as methylphenidate,
dexamphetamine, and modafinil, none of which are indicated for “cognitive enhancement” in healthy
people, and it is illegal to use these drugs without a prescription. There are as yet no pre-exam drug
tests at universities, or threats of students being stripped of their degrees as a result of “academic
doping,” but in many U.S. states the nominal penalties for diverting these drugs and using them
without a prescription can be harsh. These penalties do not seem to be often enforced.
NHMRC Australia Fellowship 569738 award to Professor Wayne Hall 2009-2013 postprint
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In the bioethics literature, cognitive enhancement has been compared to performance enhancement in
sport (e.g., Cakic 2009). However, there have been few empirical studies comparing public attitudes
toward each practice, and there are conflicting assumptions made in the literature about public
attitudes toward cognitive enhancement and sports doping that can be empirically tested. For instance,
antidoping campaigns typically rest on an assumption that the public condemns doping in sport, and
one recent survey of the Australian public found overwhelming support for strong sanctions against
athletes caught doping in sport, such as loss of sponsorship and prize money, and even criminal
convictions (Engelberg et al. 2012). However, sociologists have speculated that there actually exists a
“culture of enhancement” in many Western societies (Knorr Cetina 2005), and a number of
bioethicists have even recommended various degrees of “legalized doping” in sport, by allowing
athletes to use PEDs ((Kayser and Smith 2008; Kayser et al. 2005; Savulescu et al. 2004)). In arguing
for fewer restrictions on doping in sport, Kayser and Smith (2008) say:
Outside the sporting field, enhancement technologies like cosmetic surgery and eye surgery and use of
substances like caffeine, fluoxetine, modafinil, sildenafil, methylphenidate, and anti-ageing drugs are
an increasingly accepted social behaviour; this places zero tolerance for enhancement in sport at odds
with broader social values.
The existence of a culture of enhancement is often inferred from drug sales, but in the case of
cognitive enhancement several recent papers have shown the phenomenon is not as prevalent as
suggested by advocates in the popular media (Lucke et al. 2011a; Partridge et al. 2011). Importantly,
there are very few empirical studies in the literature that have explored whether the public accepts
either cognitive enhancement or sports doping and whether these attitudes are related. In his 2005
book Testosterone Dreams, John Hoberman links the two by suggesting that public attitudes toward
PEDs in sport may actually be a kind of referendum on other enhancements:
The question of how ordinary people feel about the doping practices of elite athletes is significant
because it indirectly addresses the status of all pharmacological enhancements in the modern world.
(Hoberman 2005)
Several recent editorials have called for investigations of public attitudes toward cognitive enhancers
to better inform policy discussions (Lucke 2012; Nadler and Reiner 2011). Nadler and Reiner (2011)
point out that many assumptions about the value of cognitive enhancement in the public's eyes lack
empirical support, and suggest that gathering such evidence is important not only for its predictive
value, but also for deciding what role “public opinion” should play in setting policies toward
cognitive enhancement. The lack of evidence on public attitudes contrasts with recent, high-profile
calls by bioethicists and others to adopt policies that could facilitate the use of drugs for cognitive
enhancement. In their Nature article, Greely and colleagues (2008) recommended allowing
pharmaceutical companies to market drugs to healthy people for the purposes of cognitive
enhancement, and proposed reevaluating legislation that prohibits the use of prescription drugs
without a prescription. These proposals assume that current restrictions on the use of prescription
drugs for cognitive enhancement may be at odds with public acceptance of cognitive enhancement
(and enhancement more generally). The American Academy of Neurology has recently defended the
ethical permissibility of prescribing drugs that are used to treat dementia, Alzheimer's disease, and
attention-deficit hyperactivity disorder (ADHD) to normally functioning people who want to enhance
their cognitive function (Larriviere et al. 2009). Yet it is not clear whether members of the public find
it acceptable for healthy people to use prescription drugs for cognitive enhancement. The same
appears to be true for legalized doping in sport.
This article reports the results of a survey of members of the Australian public that explored the
following key questions: 1. To what extent do members of the public find it acceptable for healthy
people to use prescription drugs for cognitive enhancement?
NHMRC Australia Fellowship 569738 award to Professor Wayne Hall 2009-2013 postprint
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2. What is the level of personal or vicarious “familiarity” with cognitive enhancement among the
general public? That is, what proportion of people has used prescription drugs this way? What
proportion knows someone who has?
3. Is “familiarity” with cognitive enhancement related to attitudes toward its acceptability?
4. To what extent do members of the public believe that people who play professional sport should be
allowed to use performance-enhancing drugs if they choose to do so (legalized doping)?
5. How are attitudes toward the acceptability of cognitive enhancement related to attitudes toward
legalized sports doping?
METHODS
The Survey Instrument: The Queensland Social Survey
Data collection occurred during July and August 2011 as part of the Queensland Social Survey (QSS),
a large omnibus statewide survey of views of participants in households in the state of Queensland,
Australia. Ethical approval to conduct the study was obtained through Central Queensland University,
where the survey is based. The QSS is administered through a CATI (computer-assisted telephone
interviewing) system. It includes questions from multiple research bodies and other organizations on a
wide range of topics. Among the questions, we asked participants about their familiarity with people
who engaged in cognitive enhancement:
Q1: Have you, or someone you know personally, ever taken prescription drugs—not for a diagnosed
disorder—but to enhance your normal level of concentration or alertness?
Participants were asked to answer according to the following format: (1) Yes—I have; (2) Yes—
someone I know personally has; (3) Yes—both myself and someone I know personally; (4) No; (5)
Don't know.
Next, we included two questions about attitudes toward cognitive enhancement and legalized sports
doping. Participants were asked the extent to which they agreed with the following statements:
Q2: It is acceptable for prescription drugs to be used by healthy people without a diagnosed disorder,
to enhance their normal level of concentration or alertness.
Q3: People who play professional sport should be allowed to use performance-enhancing drugs if they
want to.
Participants were asked to respond using the following response categories: (1) strongly agree; (2)
agree; (3) slightly agree; (4) neither agree nor disagree; (5) slightly disagree; (6) disagree; (7) strongly
disagree; (8) don't know.
Procedure
The target population for the telephone interview consisted of persons 18 years of age or older who at
the time of the survey were living in a dwelling unit in Queensland and could be contacted by direct-
dialed, land-based telephone service. The sample was drawn from a telephone database of randomly
generated numbers that had been selected using postcode parameters. Known nonresidential and
nonworking numbers were not included in the database. A smaller sample of randomly generated
mobile telephone numbers was also included. Within each household, one eligible person was
selected as the respondent for the interview. A respondent within each household was randomly
selected to ensure an equal proportion of male and female participants. All participants gave verbal
informed consent to participate.
Analysis
Descriptive analyses gave overall rates of familiarity with the use of prescription drugs for cognitive
enhancement; the overall rate of agreement with using prescription drugs for cognitive enhancement;
and the overall rate of agreement with legalized doping. Participant responses to Q1 were coded into
two groups: “familiar” (they, or someone they know personally, have taken prescription drugs to
enhance concentration or alertness) and “not familiar” (they had never taken prescription drugs to
NHMRC Australia Fellowship 569738 award to Professor Wayne Hall 2009-2013 postprint
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enhance concentration or alertness and didn't know anyone who had). Participant responses to Q2 and
Q3 were coded into four categories: agree, disagree, neutral, or don't know.
We used logistic regression to examine participant characteristics that predict familiarity with
cognitive enhancement (not familiar = 0 (reference); familiar = 1). The predictor variables were (a)
gender (female = 0 (reference); male = 1); (b) age in years (18–34 = 0 (reference); 35–44 = 1; 45–54 =
2; 55+ = 3); and (c) years of education (1–10 = 0 (reference); 11–12 = 1; 13–14 = 2; 15+ = 3).
We used logistic regression to see what characteristics predicted agreement with the acceptability of
using prescription drugs for cognitive enhancement. In this model, participants who responded “don't
know” or “neutral” were excluded. The dependent variable was “agreement with the acceptability of
using prescription drugs” (coded as disagree = 0; agree = 1). The predictor variables were: (a)
familiarity with those who have engaged in cognitive enhancement (not familiar = 0 (reference);
familiar = 1); (b) gender (male = 0 (reference); female = 1); (c) age in years (18–34 = 0 (reference);
35–44 = 1; 45–54 = 2; 55+ = 3); and (d) years of education (1–10 = 0 (reference); 11–12 = 1; 13–14 =
2; 15+ = 3).
We used the same method to examine predictors of attitudes toward legalized doping in sport (coded
as disagree = 0; agree = 1). The predictors were: (a) attitudes toward the acceptability of using
prescription drugs for cognitive enhancement (disagree = 0; agree = 1); (b) gender (male = 0
(reference); female = 1); (c) age in years (18–34 = 0 (reference); 35–44 = 1; 45–54 = 2; 55+ = 3); and
(d) years of education (1–10 = 0 (reference); 11–12 = 1; 13–14 = 2;
15+ = 3).
RESULTS
Sample Characteristics
The sample comprised 1,265 Australian participants (633 males and 632 females) aged 18 years and
older (range 18–101; mean = 53.7 years). Those under 35 years of age comprised 13.9% of the
sample, those 35–54 comprised 35.1%, and those aged 55 and older 50.3%. The sample varied in the
number of years of education: 1–10 (24.3%), 11–12 (22.5%), 13–14 (10.9%), and 15+ (41.2%). The
response rate was 31.9%.
Table 1 Acceptance of cognitive enhancement and use of performance-enhancing drugs
Table 2 Predictive factors for acceptability of cognitive enhancement and legalized doping
Familiarity With Cognitive Enhancement
Familiarity with cognitive enhancement was low in the sample. Most participants (89.6%; n = 1134)
said that neither they nor anyone they knew had taken prescription drugs to enhance their
concentration or alertness. Only 1 in 10 participants (10.4%) were in the “familiar” group: 2.4% of the
total sample (n = 30) said they had taken prescription drugs to enhance their concentration or alertness
in the absence of a diagnosed disorder and a further 8% (n = 101) said they knew someone who had
done so. A logistic regression analysis (χ2(7, N = 1242) = 27.462, p < .001) showed that men were
approximately 1.5 times more likely than women to be in the “familiar” group. Age was also a
significant predictor of familiarity, but education was not. Roughly 21% of participants aged 18–34
either knew someone who had used prescription drugs to enhance alertness or concentration, or had
done so themselves (6.2% of the 18–34 group had ever used). Younger participants were 2.5 times
more likely to have used prescription drugs for cognitive enhancement or know someone who had
compared to those aged 35–44, 2.65 times more likely than those aged 45–54, and 2.97 times more
likely than those aged 55 and older.
NHMRC Australia Fellowship 569738 award to Professor Wayne Hall 2009-2013 postprint
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Attitudes Toward Cognitive Enhancement
Only 7% of participants (n = 89) agreed that it is acceptable for healthy people without a diagnosed
disorder to use prescription drugs to enhance their concentration or alertness (Table 1). Eighty-five
percent (n = 1085) disagreed to any extent (42.7% disagreed “strongly” and 2.2% disagreed
“slightly”). Very few participants said they didn't know (4%; n = 51), or were neutral (3.2%; n = 40).
The logistic regression analysis examining factors predicting attitudes toward the acceptability of
healthy people using prescription drugs to enhance their concentration or alertness was statistically
significant (χ2(8, N = 1153) = 26.989, p < .001). It showed that those in the “familiar” group were
almost twice as likely as those in the “not familiar” group to agree that it was acceptable (Table 2).
Younger participants aged 18–34 were 3.2 times more likely than those aged 45–54 to find cognitive
enhancement acceptable and 2.7 times more likely than those aged 55 and older. Gender and level of
education were not statistically significant predictors.
Attitudes Toward Legalized Doping
Only 3.6% of participants (n = 45) agreed that people who play professional sport should be allowed
to use performance-enhancing drugs if they wanted to (see Table 1). Ninety-three percent (n = 1181)
of participants disagreed with legalized doping to any extent (65.9% disagreed “strongly” and 0.5%
disagreed “slightly”). Very few participants said they didn't know (1.3%; n = 17), or were neutral
(1.7%; n = 22).
The regression model predicting agreement with legalized doping was statistically significant (χ2(8, N
= 1135) = 41.737, p < .001). Gender, age, and education were not significant predictors, but attitude
toward the acceptability of cognitive enhancement was a statistically significant predictor.
Participants who said it was acceptable for healthy people to use prescription drugs for cognitive
enhancement were 9.5 times more likely to think that people who play professional sport should be
allowed to use performance-enhancing drugs if they wanted to (Table 2).
DISCUSSIONJ
Despite explicit analogies being drawn between the ethical and regulatory issues surrounding
cognitive enhancement and sports doping, this is the first time public attitudes toward the two forms
of enhancement have been assessed. The majority of our participants clearly believed it was
unacceptable for healthy people to use prescription drugs to improve their concentration or alertness.
They were even more disapproving of allowing professional athletes to use PEDs if they wanted to
(most disagreed “strongly”). Policies that facilitated the use of prescription drugs by healthy people
for cognitive enhancement (e.g., Greely et al. 2008) would be at odds with the attitudes of the vast
majority of our participants. Similarly, proposals to relax doping controls and permit the use of PEDs
in sport (e.g., Kayser et al. 2005; Kayser and Smith 2008; Savulescu et al. 2004s) would also appear
to be strongly opposed by the Queensland general public. These results provide new information
about the nature of the relationship between attitudes toward different forms of enhancement. Kayser
and Smith (2008) criticize what they see as hypocrisy in public support for “zero tolerance” toward
doping in sport while the use of drugs for cognitive enhancement is deemed a socially acceptable
behavior. Our results do not support the existence of contrasting attitudes. At least for this sample of
the Australian public, the use of drugs for cognitive enhancement was not acceptable (nor one that
was commonly engaged in), and nor was the prospect of legalized doping in sport.
Hoberman (2005) suggested that attitudes toward sports doping may be related to attitudes toward
pharmacological enhancement in general. Only a minority of our participants found cognitive
enhancement acceptable (7%), but they were 9.5 times more likely to agree that professional athletes
should be allowed to use PEDs if they wanted to. Even so, the vast majority of those who found
cognitive enhancement acceptable did not support the use of PEDs.