Making sense of pharmaceutical cognitive enhancement: taking stock and looking forward

Introduction

In this special issue of Drugs: education, prevention and policy, we bring together qualitative research drawing on theoretical frameworks from diverse bodies of literature in anthropology, sociology, psychology and applied ethics to understand, interrogate and evaluate pharmaceutical cognitive enhancement (PCE). Together, we attempt to understand motivations for, experiences of and responses to pharmaceutical cognitive enhancing drug (PCED) use individually and collectively across cultures and contexts and consider the wider implications this may have for health, well-being and drugs policy and practice. In doing so, we provide a platform for scholarly communication, critical examination and debate that we believe is necessary for us to advance our knowledge, theoretical understandings and responses (e.g. legal, ethical, social and political) to this contemporary phenomenon.

We have identified five key issues that can be found across the seven papers that comprise this issue, namely, defining, explaining, justifying, regulating and gendering PCE and PCEDs. We will consider each of these in turn before concluding with a discussion of possible future developments of and directions for the field.

Defining pharmaceutical cognitive enhancement (drugs)

The first issue that we want to draw attention to relates to the language we use to define what constitutes PCE and subsequently, what substances we recognise as being PCEDs. When reading the growing corpus of work on ‘PCE’ (Dresler et al., 2019; Farah, Smith, Ilieva, & Hamilton, 2014; LeClair, Kelly, Pawson, Wells, & Parsons, 2015; Racine & Forlini, 2010; Sahakian & Morein-Zamir, 2011; Varga, 2012), it quickly becomes apparent that there is no standard terminology to define PCE or PCEDs. Accordingly, studies of this phenomenon include a wide range of different pharmacological substances and rely on varying definitions (Coveney, 2011; DeSantis & Hane, 2010; Forlini & Racine, 2011; Greely et al., 2008; Varga, 2012; Vrecko, 2013). While the majority of papers in this issue focus their attention specifically on one or more prescription drugs (e.g. modafinil or methylpheniate, taken to improve focus, alertness and concentration), others take a broader and more inclusive approach to incorporate a wider range of substances that others may or may not consider to be ‘enhancing’ (e.g. beta-blockers, caffeine pills and hypnotics which can be taken in attempts to control levels of exam anxiety, alertness and sleepiness).

Further, scholars use varied terminology to separate ‘PCE’ from medically sanctioned or therapeutic use. However – and as those working in this area often acknowledge – this demarcation is difficult for a number of reasons (for elaboration of these points see Coveney, Williams & Gabe, 2019; Krøll, 2019 – both this issue), and language choices made can significantly impact on the scope of the subsequent inquiry and analysis. For example, Heyes (2019, this issue) provide a tightly focussed definition of PCE as ‘use of prescription drugs for purposes of augmenting cognitive abilities and improving academic performance’. In contrast, Sales, Murphy, Murphy, and Lau, (2019, this issue) start their inquiry with a broader outlook to study ‘non-medical prescription stimulant use’, defining this use as anything not sanctioned by a medical professional. Thus, enabling a wider examination of pharmaceutical use for enhancing both workplace performance and performance in social and recreational activities, and importantly, showing how the two domains are entangled with one another (Sales et al., 2019, this issue). While the more tightly focussed definitions encourage in–depth focus on a specific issue, they might be also considered prescriptive in the sense that that they may not provide enough space for participants to ascribe meaning to their actions, motivations and understandings in their own terms and in ways that go beyond this definition.

However, even when using much broader inclusion criteria some aspects of PCED use are still excluded. For instance, neither of the definitions above would include the use of pharmaceuticals to enhance an aspect of cognitive performance within a medically sanctioned treatment regime – what Conrad (2007) refers to as ‘enhancement within medicine’. This is connected to the idea that what the medical community regards as ‘normal’ in terms of cognitive health is not fixed; instead the boundaries between what is recognised as being ab/normal cognitive functioning are continually shifting. We can look to the classification and treatment of memory decline in older age for an example of this. In the past, mild memory decline would have been regarded as both a normal and expected part of the aging process. If older people experiencing this cognitive state took PCEDs, we would probably see this as form of cognitive enhancement. However, mild memory decline in older age can now be given the medical label of ‘Mild Cognitive Impairment’ (MCI) and PCEDs may be prescribed to improve cognitive performance. Whether medical prescription of PCEDs for improving cognitive functioning should be regarded as ‘enhancement within medicine’ or not is a subject of debate. Importantly, Williams, Katz and Martin, (2011, p. 231) argue that developments in ‘memory medicine’ are ‘shifting the boundaries of cognitive health’, thus changing our perceptions and expectations of ‘normal’ cognitive functioning. Consequently, Coveney et al. (2019, this issue) refer to PCEDs as ‘slippery’ objects in reference to their multiple conceptualisations and meanings in public discourse, arguing that it is important to recognise that these different definitions and understandings of PCEDs are not perceived to be equally morally acceptable in public discourse.

Next, we turn to explaining use, a key theme that cuts across all of the papers in this Special Issue.

Explaining use

The issue of why people use PCEs has received a lot of attention in the literature. While large scale quantitative studies (Maier, Ferris, & Winstock, 2018; McCabe, West, Teter, & Boyd, 2014; Schelle et al., 2015; Singh, Bard, & Jackson, 2014) typically allow participants to select ‘motivations’ for PCED use from a pre-defined list, the emerging body of qualitative literature on PCE gives more in-depth data on how PCE drug use is positioned, negotiated and understood by users in the context of their everyday lives (Coveney, 2011; Williams, Coveney & Gabe, 2013). A common thread across all studies in this issue is acknowledgement of the underlying cultural context of drug use. It appears that the contributors generally accept the idea that we are living within a ‘performance society’ where there is pressure on individuals to ‘do well’ in many spheres at once (Bjønness, 2019 both this issue; Krøll, 2019). Collectively, the contributions in this issue highlight how pressures to perform at one’s best, to ‘keep up’ with others, to be productive and competitive and to balance work and social life are prominent, particularly in occupational and educational spaces.

Discourses about PCEDs are imbued with promises to provide users with cognitive benefits such as improving ability to focus on tasks for longer periods of time, to increase alertness, to heighten enjoyment of performing cognitive tasks and to reduce need for sleep (Coveney, 2010; Williams, Higgs, & Katz, 2012). But further to this and perhaps more significantly, it is the social and emotional aspects of this improved cognition that seem to prove most alluring – increased productivity and efficiency, a way of controlling and managing pressures, a mechanism through which to gain more time and a way to improve work-life balance.

While the focus on performance in discourses around PCEDs may for some constitute an important discursive resource for identity-making, it can also create a sense of marginalisation for others (Sørensen, Pless, Katznelson, & Nielsen, 2017, 27). The imperative both to be autonomous, successful and happy, may not always be possible to live up to (Petersen & Willig, 2004). The ‘convergence of different pressures’ (Steward & Pickersgill, 2019, this issue), can then exacerbate the feelings in people that they are not coping, falling behind their peers, not reaching their potential or not meeting expectations. Thus, feelings of insufficiency – or never reaching the finishing line (Sørensen et al., 2017; Willig, 2005) – may create a space for what has been termed the ‘pharmaceuticalisation of performance’ (Lopes, Clamote, Raposo, Pegado, & Rodrigues, 2015).

It is evident that PCEDs can take on many roles in people’s everyday lives, from self-medications to treat perceived performance deficits to tools of emancipation, a way ‘customising’ (Williams et al., 2013) their body and its biological rhythms to align with social rhythms (Coveney, 2014; Krøll, 2019, this issue; Steward & Pickersgill, 2019, this issue). Thus we might think of people using PCEDs to ‘meet felt requirements to become particular versions of themselves’ (Bjønness, 2019, this issue) in creative and individual ways, which has further implications for how we conceptualise PCE (see Coveney et al., 2019, this issue).

Moralising, justifying and (de)legitimating PCE

The third issue we consider in this editorial is how pharmaceutical cognitive enhancement comes to be legitimated/prohibited, justified/condemned and moralised across different socio-cultural contexts. Not only has this been a substantial focus in the field to date, it can also be considered a major theme across all of the contributions in this issue.

Ethical debates around the ‘promises and perils’ (Hyman, 2011) of cognitive enhancement have flourished over the past 15 years and show no sign of slowing down. A number of reports from various countries (e.g. Danish Council of Ethics, 2011; King, 2005; Nuffield Council on Bioethics, 2019) suggest PCE as a pertinent area for further ethical consideration. As new and existing drugs are explored across a myriad of social contexts, from educational settings to the workplace, in the military and in sport, these considerations include whether use of cognition enhancing drugs would give users an unfair advantage over others, whether this can be seen as cheating, and whether using drugs to ‘reshape the human’ condition is ‘playing God’.

Complimentary to this, there is an established and growing body of work in the field of medical sociology that illustrates how the consumption of medicines in daily life is a highly moralised issue (Gabe, Coveney, & Williams 2016; Gabe & Lipshitz-Phillips, 1982, 1984; Gabe & Thorogood, 1986; North, Davis, & Powell, 1995; Polak, 2017; Reubi, 2013; Venn & Arber, 2012). Different substances, contexts of use and user groups attract diverse moral evaluations. The ‘non-medical’, ‘off-label’, ‘social’ or ‘lifestyle’ use of PCEDs is no exception.

Studies have found that the social acceptability and normative evaluation of PCED use is contextually dependent. It appears that PCED use is more likely to be evaluated in positive terms or regarded as acceptable if motivations for use are aligned with dominant cultural values, of healing, of hard work and of greater productivity (Coveney et al., 2019; Sales et al., 2019, both this issue). Use becomes more ethically contentious in social contexts where PCED use could be considered as ‘cheating’ or providing an unfair advantage to the detriment of others, and Higher Education has typically been studied in this regard (Bjønness, 2019, this issue).

In his study Heyes (2019, this issue) examines the psychological mechanisms or ‘moral disengagement’ that students use to justify and rationalise their use of PCEDs in ways that allow them to not feel guilty about drug use in higher education contexts. One such mechanism, which can be evidenced across many studies on PCEDs (De Santis & Hane, 2010; Loe & Cuttino, 2008; Sales et al., 2019; Steward & Pickersgill, 2019, this issue) is what Heyes (2019, this issue) refers to as performing ‘favourable comparisons’ of PCEDs with other substances to minimise their possible harms and to normalise the idea of their consumption in particular social milieus. Similarly, Bjønness (2019, this issue) views such comparisons as ‘legitimising strategies’.

Further, recent studies of PCED users have found that their moral evaluations of PCED use continually shift within the same social context as social and time pressures rise and fall (Krøll, 2019; Steward & Pickersgill, 2019, both this issue). For example, it is well established in the literature that students tend to use PCEDs at times of increased pressure (e.g. around exams and before deadlines) (Maier et al., 2018). During these times, a sense of urgency or ‘crisis’ can provoke a shift in personal ethics where drug use is considered more of a necessity than a choice as a mechanism of managing performance and achievement. Thus, a sense of ambivalence is often embedded in narratives around PCED use (Bjønness, 2018; Krøll, 2019, this issue; Loe & Cuttino, 2008).

Empirically, we still do not know much about the extent to which these drugs are being used outside of pressured and competitive situations, and are only beginning to start to acknowledge and recognise how their effects might spill over into other aspects of our social and emotional lives – and vice versa (Lopes et al., 2015; Sales et al., 2019, this issue). It is important to recognise that ‘work’ cannot be easily demarcated and compartmentalised as a discrete sphere in contemporary societies, where working practices and patterns are shifting and work time and leisure time are becoming increasingly blurred. Thus, future empirical studies on consumption of PCEDs and ethical deliberation around the acceptability of their use would benefit from acknowledgment of these wider social cultural shifts.

Regulating PCEDs

Next, we turn to the issue of regulation. Papers in this issue focus on PCED use in three different countries – Denmark, the United States and the United Kingdom. In the US possession of stimulants without a prescription is a criminal offence, whereas in the UK and Denmark possession is not against the law, but sale of these medications or intent to supply is criminalised. Despite these legal differences, it is fair to say that all take a broadly prohibitory stance towards pharmaceuticals with the potential to be used as cognition enhancers. Drug policies then, centre on efforts to restrict the supply of these drugs (e.g. through prescription mechanisms) and to limit associated criminal activity (e.g. criminalising sale of these substances).

However, it is important to recognise that legal and regulatory approaches to PCEDs are entangled with the ‘social lives’ (Cloatre & Pickersgill, 2014, 435) of these pharmaceuticals and their primary purpose as medicinal products. Namely, that typically these pharmaceuticals are owned (through patents) and manufactured (often by large and powerful global pharmaceutical companies), they are tested, labelled, packaged, licenced, marketed, sold and prescribed as treatments for specific medical indications. Uses outside of those that are medically sanctioned can then easily be defined as abuses of prescription medicine. PCEDs are typically not linked to addiction, crime and mortality as is the case for "traditional" illegal drug use (Hunt & Barker, 2001). Instead, the (ab)use of pharmaceuticals for cognitive enhancement is often rather problematised by discussing ethical dilemmas about justice and cheating, the natural and chemical as well as the authentic and artificial (Chatterjee, 2004; Coveney, Gabe, & Williams, 2011; Dees, 2008; Farah et al., 2004; Forlini & Racine, 2011; Hildt, Lieb, & Francke, 2014; Loe & Cuttino, 2008; Maslen, Faulmüller, & Savulescu, 2014; Nagel 2010; Petersen, Nørgaard, & Traulsen, 2015; Parens, 1998).

Thus, the regulatory contexts within which this is taking place is central to not only how they come to be ‘apprehended by law, constituted through legal processes and regulated on the market’ (Pickersgill & Hogle, 2015, 136) but also to how they come to be positioned, understood and their use normatively constrained in everyday life (Coveney, Nerlich, & Martin, 2009; Coveney, 2011; Gabe, Williams, Martin, & Coveney, 2015).

However, and as several scholars assert, this prohibitory stance and identity of these substances as prescribed or controlled medicines does not appear to be putting everyone off using them as PCEDs, (see for example, Bjønness, 2019; Petersen & Petersen, 2019, both this issue). Furthermore, studies have found that some PCED users regard the medicinal status of PCEDs as a symbol of their safety despite their consumption practices falling outside of medically sanctioned uses (Bjønness, 2018).

As mentioned above, research with users of PCEDs has demonstrated a deep routed sense of ambivalence around their use. This not only stems from the ways in which PCEDs are regulated as medicinal products, but also in how they are then accessed (e.g. see for example Vrecko’s (2013) work on drug divergences) and come to be used. Importantly, the ways in which those in positions of authority – from doctors, teachers, police officers to parents – react to PCED use can further add to ambiguities around their social acceptability.

In their paper, Petersen and Petersen (2019, this issue) tackle the issue of coercion, regarding this as one of the main ethical concerns around PCED use that is used to justify prohibitory regulatory positions. They discuss tensions between perceived agency (free choice) of users and external and/or implicit pressure to take PCEDs in order to perform. They argue that their findings raise doubts over whether ‘fears of coercion’, which, they say are used to justify the current prohibition of PCEDs, can in fact be substantiated by ethical analysis. They discuss whether it is morally justifiable to prohibit access to PCEDs if use is considered by the user to be a free choice and go on to suggest the consideration of proactionary rather than solely precautionary approaches to regulation (also see Coveney et al., 2019, this issue). Nevertheless, for PCEDs to be made more widely available to ‘healthy’ people – a sentiment expressed by some commentators (e.g. Greely et al., 2008), a shift is needed in existing regulatory regimens that would facilitate the legal and regulatory approval of novel and existing pharmaceuticals and create routes for consumption of these substances outside of the medical sphere (Gabe et al., 2015).

Gendering PCE

The final issue we want to draw attention to relates to gender and PCE, which has been relatively neglected in the research on PCED to date.

Although only one of the papers in this Special Issue explicitly focuses on gender, there is a large body of work that demonstrates how dominant discourses of medicine and drugs also contain more or less underlying or hidden discourses about the reproduction and reconstruction of gender (Blum & Stracuzzi, 2004, 270; Hunt & Antin, 2019). A well-known example here is of the drug Prozac, which in the 1960s, often labelled ‘mothers little helper’ carried with it latent gendered messages, including to ‘discipline elite female bodies, to enhance their productivity and flexibility’ (Blum & Stracuzzi, 2004, 270). In contrast, in the 1990s, Prozac was labelled quite differently, and was placed ‘among the hippest of advanced technology products’ (ibid). The Prozac case illustrates that bodies and minds are historical objects, and that growth of certain kinds of use in specific periods, signals something about this period of time.

In addition, there is a large body of work in Science and Technology Studies (STS) on gendering technology, analysing how technologies come to be gendered in their development and use (see for example Mamo and Fishman (2001) on Viagra as pharmaceutical technology of the gendered body and Oudshoorn’s (1999, 2002) work on contraceptive pills and other gendered artefacts). From this theoretical perspective, technologies (including pharmaceutical drugs which are regarded as ‘pharmaceutical’ or ‘medical technologies’) are thought as being part of complex and heterogeneous ‘socio-technical systems’, emphasising the idea that material objects and social practices are inseparable from each other. Through this lens then, we come to recognise that pharmaceutical drugs are not neutral artefacts, but are designed, developed and promoted for specific reasons and therefore embody social, cultural and political values (Coveney, 2011; Potts, Gavey, Grace, & Vares, 2003; Rose, 2007).

In recent research a growing interest on the ways in which the motivations for and justifications of medicine/drug use differ between males and females has emerged. This research has understood gender as constructed and reconstructed in social settings and relations (Bailey, Griffin, & Shankar, 2015; Campbell, 2000; Ettorré, 2007; Miller, 2001), and underlined and illustrated the great complexity in the ways in which men and women ‘do gender by doing drugs’ (Measham, 2002). The advantage of thinking about drug use this way, is that it allows analyses of how interactions are influenced both by normative and situational gendered scripts, and how drug use may be a way of experimenting with different forms of masculinity and femininity (Connell, 1995; Pyke & Johnson, 2003).

Bringing this corpus of work into conversation with the existing literature on PCED use will enable us to further explore how PCEDs, and the discourses around them, act to (re)shape gender norms, and reinforce gendered patterns of power and authority. Moreover, we might further consider, building on Bjønness (2019, this issue) pioneering work in this area, how use of PCEDs under certain circumstances may be regarded as a strategy of resistance against dominant norms. In relation to PCEDs, we are only beginning to unravel gendered ‘socio-cultural scripts’ (Coveney, 2011) around their uses, including the importance of, for example, gendered media representations of achievement on the PCED consumption practices of young people (Bjønness, 2019, this issue). Following earlier works, examining narratives about PCED use may thus give us important information about current gender arrangements.

Summary and future agendas

It is hoped that collectively, the papers presented in this issue have furthered our understandings and analysis of PCED use across contexts and cultures. The articles in this issue have contributed to the understanding of motivations for and experiences of PCDE use regarding the wider implications this may have for health, well-being and drugs policy and practice. Indeed, these are complicated processes that we are only starting to grasp. Thus, it has been a valuable endeavour to bring together work from different societies, theoretical perspectives and population groups to be able to compare and contrast findings and develop our conceptual and theoretical understandings of PCE and PCED use. Yet, it is apparent that a number of challenges remain, including the need for more detailed case studies of specific drugs, as well as further comparative and historical work.

To summarise, collectively, the papers in this issue have demonstrated the following four key messages, that:

1. There is a lack of standard terminology and definitions of PCE and PCEDs, and accordingly, studies include a wide range of different pharmacological substances. This lack of clarity also means that demarcations, for example between ‘pharmaceutical enhancement’ and ‘therapeutic use’ are difficult to make, which may impact on future inquiry and analysis, particularly in terms of encouraging further cross-disciplinary dialogue;

2. It is important to include the wider social and cultural context of PCED use, (for example the perceived expectations and pressures on us within ‘the performance society’, the increasing blurring of work and leisure time, the legal and regulatory context within which pharmaceuticals are constituted, and (the often gendered) cultural discourses about well-being and enhancement), as well as the specific empirical situation of the use in the analysis of the motivations, negotiations, consumption patterns and practices and identity work of PCDE users.

3. PCED use is often imbued with a sense of ambivalence and users draw on and develop different strategies to account for and legitimate their varied consumption practices. The articles in this issue illustrate that the tension presented by a lot of the participants between societal demands to be a certain kind of ‘self’ or ‘person’ and their experienced freedom or opportunity to fulfil these demands, often contain a sense of uncertainty. Many seem to doubt whether their use is acceptable and fair, and there is a lack of clear policy in the field.

4. Despite the wealth of ethical discussion and deliberation that has taken place to date, PCDE use continues to be a highly contested and ethically debated issue. However, it is clear that the social acceptability and normative evaluation of PCED use is contextually dependent. The articles in this issue indicate that PCED use is more likely to be regarded as acceptable if perceived motivations for use are aligned with dominant cultural values in western societies like hard work and greater productivity, and more likely to gain a negative assessment when associated with ideas about cheating and gaining an advantage over others. However, different pharmaceutical substances, contexts of use and user groups attract diverse moral evaluations that are continually shifting in response to ever changing social and environmental conditions.

We would like to end by drawing attention to three areas for future research, arguing that there is a need for us to push towards theoretical understandings of PCED that are both more nuanced and more comprehensive.

First, and as noted above, contributions in this issue are from scholars in Denmark, the UK and the United States, reflecting the existing dominance of Northern European and North American viewpoints in the field to date. There also has been some research into PCEDs in Australia and New Zealand (Jensen, Forlini, Partridge, & Hall, 2016; Lucke et al., 2018; Mazanov, Dunn, Connor, & Fielding, 2013; Partridge, Bell, Lucke, & Hall, 2013; Partridge, Bell, Lucke, Yeates, & Hall, 2011; Ram, Hussainy, Henning, Jensen, & Russell, 2016) and a small number of studies conducted in other cultural contexts such as South Africa (Beyer, Staunton, & Moodley, 2014) and Brazil (Ortega et al., 2010). However, the lack of attention given to PCEDs in other cultural contexts, such as China, South Asia and across African nations for example, is notable. There is then, a need for scholars to look beyond the ‘West’ and take a more global and comparative perspective to examine understandings of PCE and PCED consumption practices in varied socio-cultural and regulatory environments. Because PCDE use has often been connected to the pressure and stress in western educational institutions and workplaces (Bjønness, 2019, Steward & Pickersgill, 2019, all this issue; Krøll, 2019; Maier et al., 2018; Sattler, 2019), comparative work, analysing different settings and contexts, would help us gain a more nuanced knowledge about the phenomenon. We might also think of future work around pharmaceutical production and ‘global supply chains’ and how these act to shape consumption practices, to uncover and connect the production and manufacture of pharmaceuticals – which often takes places within developing countries – with their distribution, sale and use (Gabe et al., 2015).

Not only would this enable us to develop more comprehensive theoretical understandings of PCEDs and how consumption practices, values and ethical judgements are tied to social context, but also enable deeper critical reflection of key concepts at the core of these issues.

Second, it is evident that our understanding of how structural factors – such as age, social class, ethnicity, sexuality and gender – influence and are influenced by PCED use is underdeveloped. As mentioned, recently, there has been some move forward in regard to understanding gender and PCED use, informed by seminal sociological work on how women drug users ‘do drugs’ in order to ‘do gender’ (Measham, 2002; West & Zimmerman, 1987). A renewed focus on gender is proving worthwhile and there is no doubt scope for further work to be done to explore how PCED use is both shaped by and acts to shape/reinforce/resist gendered social norms. However, a focus on gender alone is potentially limiting in regard to recognising other forms of differentiation and inequality (Miller & Carbone-Lopes, 2015). We thus advocate for future studies to take an intersectional approach (Crenshaw, 1989) to the use of PCEDs to explore intersecting patterns between different power structures and how people are positioned and position themselves – in multiple categories such as gender, class and ethnicity (Christensen & Jensen, 2012, 110, Miller & Carbone-Lopez, 2015; Phoenix, 2011). In order to grasp the complexity involved in motivations for, experiences of and responses to PCED use individually and collectively, we need a focus on how different social categories mutually constitute each other as overall forms of social differentiation, thus creating complex and changing identities (Christensen & Jensen, 2012, 110).

Lastly, we look to the media to consider the ready-made narratives they provide (Coveney et al., 2009) in the ‘governance of not only our bodies’ (Williams, Seale, Boden, Lowe, & Steinberg, 2008) but our minds too. Williams et al. (2008) argue that the media – both old and new – is a key way in mediating and promoting a pharmaceutical to the public. The stories which are selected and those which are ignored, the narratives through which they are told, the parts which are emphasised and details missed out and the pattern of meanings contained within media messages are all part of the way in which media filter our experiences and can ‘shape our experiences of the world’ (Shoemaker & Reese, 2013).

In future work we might critically consider the role of social media and the Internet more generally, in terms of facilitating access to information about drugs, as gateways for their consumption through their purchase online, and in terms of creating new spaces for challenging prevailing understandings and uses of pharmaceuticals. Additionally, and building on from earlier work in this area, we might further examine the narratives around PCE that are present in media sources, the language and vocabularies through which we assemble our understandings and experience of PCE, and to consider what ‘subject positions’ (Bjonness, 2019 this issue) are being made available to us.

In relation to future policy responses to PCEDs, it would be helpful if authorities were more explicit about their approach to pharmaceutical cognitive enhancement, so that the responsibility and thus the ambivalences did not fall so heavily on the individual. However, a focus on drug policy in a sense obscures other political and social responses to do with how we structure and regulate work, studies and leisure time in our daily lives. Collectively, the body of work on PCEDs brings to bear pertinent observations about the omnipresence and pervasiveness of the ‘performance society’ in the West and throws an uncomfortable spotlight on some of the destructive and damaging impacts this development can have on individuals. This calls for a radical rethinking of how we structure our work lives and educational environments in such a way that does not lead to drugs being considered the best or perhaps only option for people to cope. Undoubtedly, more work is needed to further scrutinise and propose alternatives to the structural conditions that give rise to unrelenting pressures to perform, essentially creating conditions or spaces for PCED use in the workplace and higher education to emerge.

Although great strides have been made in building a body of knowledge to explain, account for and ethically examine the contemporary phenomenon of pharmaceutical cognitive enhancement, notable gaps in our understanding are still apparent. As we pause to take stock, the ground continually shifts beneath our feet; new and old pharmaceuticals find novel uses as enhancers while others might fall out of favour; poly drug use becomes a prevalent policy concern where pharmaceuticals are mixed with other non-pharmacological drugs or new psychoactive substances; consumption practices mutate, adapt and develop, overlapping with changing values and personal ethics which can move position, alter and transform as cultural pressures, priorities, needs and desires also change. The value of future work on PCEDs will be in not only addressing the current gaps in the field, but also recognising the shifting sands on which we stand and developing ways to acknowledge and account for this both theoretically and empirically.

Catherine Coveney
Social and Policy Studies Unit, School of Social Science, Loughborough University, Loughborough, UK
[email protected]

Jeanett Bjønness
Centre for Alcohol and Drug Research, Aarhus University, Aarhus, Denmark
[email protected]

Disclosure statement

No potential conflict of interest was reported by the authors.