Keywords

Three observations form the starting point for this book: Firstly, mental disorders are being diagnosed much more frequently, with psychopharmacological drugs increasingly prescribed as treatment. Secondly, cognitive enhancement or neuroenhancement is more often discussed in the academic literature and in the media. And thirdly, psychoactive substances—or “drugs”—are commonly being consumed for a variety of reasons. These topics will be addressed in turn: Chap. 2 focuses on mental health, Chap. 3 on enhancement, and Chap. 4 on substance use.

The link between these observations is the concept of health. Mental disorders are commonly diagnosed by a clinical expert when there is a cognitive, emotional, or behavioral problem associated with significant (1) subjective suffering and/or (2) impairment in one’s daily activities. As an improvement beyond one’s “normal” capabilities, enhancement is usually—and sometimes perhaps even axiomatically—distinguished from medical treatment. Lastly, whether a substance is perceived as either a medical or—a potentially illicit—“recreational”, a “lifestyle”, or a “smart” drug depends on whether medical and political institutions recognize it as a suitable treatment for a health problem. In 2003, the US President’s Council on Bioethics contrasted treatment with enhancement in its report Beyond Therapy: Biotechnology and the Pursuit of Happiness, defining it as: “the directed use of biotechnical power to alter, by direct intervention, not disease processes but the ‘normal’ workings of the human body and psyche, to augment or improve their native capacities and performances” (President’s Council on Bioethics, 2003, p. 13).

These experts—who included biologists, ethicists, philosophers, physicians, and scholars of law—were fully aware of the tentativeness of this distinction, as the quotation marks around the term “normal” indicate. Yet, for most of the bioethicists and neuroethicists, the latter being a new kind of specialist particularly addressing the ethical challenges of brain research, medical diagnosis mattered a good deal: They commonly discussed issues such as safety, coercion, or fairness related to the “non-medical” use of performance-enhancing drugs, but barely problematized or even reflected on the sharp increase in the number of medical prescriptions. And that while the same substances were often consumed in both domains, medical and nonmedical—the majority, as we will see later, under a doctor’s prescription. Physicians appeared to possess a magic wand: As soon as they declared something to be “medical”, critical reflection became inappropriate.

Questions about, say, overdiagnosis or overprescription were left to medical sociology, which has traditionally investigated the process of medicalization. This term refers to extending the purview of medicine such that more and more problems of everyday life are first defined and then treated as medical problems (see, for example, Bell & Figert, 2012; Busfield, 2017; Conrad, 2005). Similarly, the complex field of drug policy was left to criminology, law, and addiction medicine, while many of the possible candidates for pharmacological cognitive enhancement are in fact strictly regulated substances—because of their “abuse potential”, as the authorities say. This implies that people who take them are violating the law in many jurisdictions, literally becoming “illicit drug users”, unless a physician has sanctioned their action (remember the magic wand).

The situation is made even more complex by the fact that the concept of health in itself—like “normal”—is ambiguous, with different accounts competing with each other. Since 1946, the famous and very broad definition from the preamble to the constitution of the World Health Organization (WHO) has defined it as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.Footnote 1 But if, for example, students’ mental and social well-being significantly depended on them passing courses or even getting excellent grades, wouldn’t that make their use of performance-enhancing drugs medical, whether they had a prescription or not? And, following this train of thought a bit further, doesn’t social well-being also depend on the economy? Do we then need physicians to combat unemployment, inflation, or economic crises? This shows us how a broad definition like that of the WHO can turn virtually anything in our lives and societies into a medical problem.

More recently, an interdisciplinary team of researchers who featured on the title page of the British Medical Journal proposed that health be defined as “the ability to adapt and to self-manage” (Huber et al., 2011, p. 3). Doesn’t that make the treatment-enhancement distinction collapse altogether? This is because the use of psychoactive substances to achieve particular aims in a certain social context could then be understood as successful adaptation and self-management. This argument can be reinforced still further by the “six pillars of health” that these experts validated in subsequent research, namely (1) bodily functions, (2) mental functions, (3) the spiritual/existential dimension, (4) quality of life, (5) social participation, (6) and daily functioning (Huber et al., 2016). Health then ceases to be a distinct category and instead becomes a spectrum or continuum associated with virtually all aspects of our lives. Employing such a complex or holistic concept of health, all attempts to improve one’s live with regard to any of these six dimensions could be understood as related to health and not specifically a kind of enhancement in the “beyond normal” sense.

The Aim of This Book

This book is intended as an essay in the literal sense, that is, an attempt to see what happens when the ever-problematic distinction between treatment and enhancement is abandoned. This effort is further supported by the fact that the domain of mental health is by no means clear, either: There, we witness the persistent absence of biological features (also called “biomarkers”) to diagnose mental disorders in combination with often fuzzy diagnostic criteria and even “not otherwise specified” categories for atypical cases. This ultimately leaves it to the discretion of a clinical psychologist, psychiatrist, or other medical professional as to whether a person’s psychological problem is deemed “clinically significant”, as we will see in more detail in the next chapter. It is important to understand from the outset that the perspective taken here focuses on clinical experts and their institutions; it by no means denies the reality of people’s problems, their suffering, or their impairment!

This book thus aims (or dares?) to ask what happens with cognitive or neuroenhancement on the one hand and a substantial proportion of the psychopharmacological treatment of mental disorders on the other if the treatment/enhancement distinction is set aside. How can we then make sense of the sharp rise in substance use over the past 30 years? Can we better understand this social change, this vast increase in the number of psychoactive substances consumed in many societies, if we investigate it more neutrally as instrumental use, that is, as individuals’ decisions to achieve certain aims in personally or socially meaningful contexts? And are there any historical precursors that could guide our endeavor?

To answer these and related questions, we start with a deeper analysis of mental health and disorders in the next chapter. Philosophers have developed a useful framework to make sense of “things” that we will apply to better understand what these disorders, so frequently diagnosed nowadays, actually are. The concept of addiction will receive particular attention because of its close link to substance use. We will also discuss recent trends and scientific findings to evaluate whether the prevalence of mental disorders is actually on the rise, as media reports so frequently suggest.

From mental health in Chap. 2, we will move on to mental enhancement in Chap. 3, where we will first aim at a better understanding of the academic debate. A look at surveys on consumption will reveal how realistically leading scholars in the field and the media represent the (allegedly new and increasing) phenomenon. To do justice to the book’s title and go beyond the scholarly discussion of neuroenhancement, we will also address nonpharmaceutical means to improve one’s psychological functioning and mental well-being.

Understanding the essential basics of mental health and enhancement will allow us to look beyond these categories—and in particular the treatment/enhancement distinction. The focus of Chap. 4 will thus be instrumental substance use. It begins with a conceptual discussion of how we categorize different kinds of substances as “drugs” and what these classifications imply. The subsequent section on instrumental use will summarize several examples and answer the question of what psychoactive substances are good for when used properly. Historical examples will further support this way of thinking about substances. The subsequent section on moral values will describe different perspectives that we can take on that topic and thus provide guidance for drawing our own ethical conclusions. The fifth and final chapter will combine an overall conclusion with suggestions about further issues to investigate, and I will also draw a personal conclusion from my own point of view.

Mental Health and Enhancement: Substance Use and Its Social Implications thus combines knowledge and research from psychology and the social sciences, psychiatry and epidemiology, as well as philosophy and ethics. Present trends likely affecting hundreds of millions of people worldwide are put in a historical context (e.g., Jay, 2010), reflected upon theoretically, and contrasted with common frames in science communication. All chapters illustrate how concepts and definitions affect the work of clinical and scientific experts as well as the public at large, which in turn impacts on the concepts and experts’ work. In doing so, the book will argue to avoid essentialistic fallacies underlying limited understandings of terms like “disorder”, “enhancement”, and “drug”. Eschewing these limitations, instrumental substance use will turn out to be an alternative and more comprehensive analytical category to describe and make sense of people’s behavior in various social contexts, which should also inform ongoing debates and decisions on drug policy.