From the perspective of her physician, Ms. P. would seem to be the optimal candidate for “cognitive enhancement,” as she seeks, respectively, stimulant or antinarcoleptic medications like Ritalin or Modafinil to sharpen her mental focus rather than to treat a disease. She is a well-educated professional, who has come very close to her goals without the aid of pharmacology. She deferentially seeks expert guidance and presumably her physician’s blessing. She acts responsibly and sensibly, avoiding the specter of the drug-seeking patient. ^{Footnote 1} And finally, she is “well known” to the provider, from which one can infer a relationship of trust and openness, the precondition for the ideal of “shared decision making” between physicians and patients. ^{Footnote 2,Footnote 3} By painting the picture of a perfect patient, this case removes some of the obvious concerns around cognitive enhancement, cutting a path that outflanks well-trodden concerns about safety or coercion to arrive at a tension deep in the thicket of ethical questions around pharmacological improvement: is there something fundamental about physicians’ art that prevents them from aiding a patient who does not require relief from disease? The patient does not seem to think so. Indeed, she says “I wanted to come to you to do it [get medications] the right way”.

If enhancements are by definition ethical because they end up making people’s lives better, the answer is surely yes. ^{Footnote 4} If there is a morally salient distinction between treating disease and improving function beyond whatever is considered “normal” for that individual or for a group of individuals, as the question has frequently been posed, the answer is less clear. ^{Footnote 5,Footnote 6,Footnote 7} Rather than looking at this from the vantage point of how medicine and enhancement are defined, and which normative judgments this entails, I want to leave the ethics of that question aside, focusing instead on how enhancements are imagined, and what this might imply for how physicians care for their patients.

Research shows that cognitive enhancements are widely believed to allow individuals to avoid sleep while remaining productive and efficient, boosting performance far beyond normal bounds as part of a general ethos of performance and self-optimization, ensuring that personal and professional goals will be realized. ^{Footnote 8,Footnote 9} These medications supposedly allow individuals to “tailor” their bodies using medications, a claim indebted both to historical visions of biological engineering that still forms part of the backdrop of the “smart pill,” and to the notion of self-experimentation with pharmaceuticals. ^{Footnote 10,Footnote 11} Moreover, media reporting on medications for enhancement tends to normalize their use through claims that their use is as “as common as coffee,” ^{Footnote 12} as many people, including academics, are taking Ritalin or Modafinil as a regular part of their everyday work. ^{Footnote 13} This information matters: qualitative literature demonstrates that those taking enhancements believe them to be safe because they are licensed pharmaceuticals rather than street drugs, and when used for “the right reasons” such as performance improvement. ^{Footnote 14} In the popular narrative about cognitive enhancements, they are obviously good things (as the name suggests), arguably because they realize values of individual performance, self-control, and self-fulfillment central to contemporary Western ethics. Therefore, when Ms. P. speaks about her predicament, it is through the lens just sketched: her future now hinges on a single set of examinations that she simply cannot pass without pharmacology, a trepidation stemming from her declining grades and her judgment that she is no longer as good as her classmates. She has seized on modern pharmacology as the solution, which she has read can help her study better and longer, and can help her remember more; a quasimagical elixir for the brain. Putting her account in slightly different terms, in Ms. P.’s ethical imagination, she has reached the limits of her own agency in the competitive marketplace of talent, which will preclude her from realizing her (professional) self-fulfillment, and necessarily needs a technological solution that will straightforwardly optimize her biological capacities.

This framing shapes the normative dimensions of the meeting with her physician in a moment of crisis: the choice is whether to prescribe (or take) medications for enhancement. Annemarie Mol describes this emphasis as “the logic of choice,” in which “making normative judgments is the moral activity par excellence,” and the form in which much of medical care is delivered: there is a single point in time at which a patient makes a decision, after full consideration of all the facts that the physician provides, for which the patient typically assumes responsibility. She describes the alternative as a “logic of care,” in which the physician and patient are working together engaging in what she describes as “tinkering,” a kind of experiment that tests what can be done against what works, and readjusts. ^{Footnote 15} In emphasizing care over choice, Mol points out that caring for someone is an ongoing practice seeking to discern what is good for that patient, which may shift, rather than a more transactional arrangement at a single point in time.

What would it mean to try to care for Ms. P., rather than to simply approach her predicament as a question of choice? To begin, when Ms. P. speaks about her dilemma, her narrative is perhaps a testament more to her angst than her predicament; her situation may not be as dire as she feels that it is. After all, she has made it through law school, and is competent enough to have a job waiting for her. It would be prudent to explore what she expects, hopes, and fears will happen, and perhaps offer reassurance. Medications used for cognitive enhancement seem to primarily alter emotions, increasing motivation rather than attention or memory; ^{Footnote 16} this matters because drugs will improve her affects rather than biology, which may be amenable to more than just pharmacology. She may ultimately benefit from being prescribed medications, but a perspective of care would dictate that this happens after her physician has fully understood her predicament, and both have worked to find a solution that acknowledges what she might need, and what the technology can and cannot do; all with the understanding that the answers to the latter question are only incompletely known. ^{Footnote 17} In sum, framing the normative questions about whether enhancements are “ethical” only in terms of whether choosing to take or prescribe them poses risks both in believing that biological optimization is the primary goal, and in being blind to the many entanglements that enmesh those seeking pharmacological improvement.