Hi, welcome to this session of Neuroethics. I'm Jonathan Moreno.

In this session we'll be talking about lifestyle drugs, and I want to acknowledge especially the work of Rod Flower in this segment. So, what are lifestyle drugs. what is lifestyle medicine? A phrase we're hearing more and more these days, and it's very relevant to neuroethics for reasons that we'll talk about in this segment. So a lifestyle medicine is a medicine that is used to satisfy a non-health related goal. Baldness, erectile dysfunction, female sexual dysfunction, even shyness, have been on the list for lifestyle medicines. They're different from our traditional conception of medicine in a number of ways that I'll talk about in the next few minutes. But for one thing because they're really not treating a disease in some kind of essential way, necessarily. They might be treating something that's sort of on the margins of what we think of uncritically of health and disease. They might be used to increase our well being. perhaps to enhance it. A term we'll be using a lot in this course, but not in a traditional way to treat a disease. these lifestyle medicines also include over-the-counter preparations, things that you might find in your drugstore. Things you might find in the herbal medicine or holistic medicine department of your store, of your grocery store, your super market. often they are taken to improve pleasure experiences, not necessarily to enhance performance. and another thing about these medications is that they have attracted a lot of attention in media. In fact, might even almost say that lifestyle medicines are what they are because of all the media attention that surrounds them. you can almost define a lifestyle medicine by

whether it has received media attention as kind of an interesting new option for people to live a somewhat different way, to improve themselves in some way. But that leads us to the question really a pretty hard question. what is a patient? What is it to be a patient? You're being treated for a traditionally conceptualized disease, which we'll have to return to, as a problem in defining in itself. you're a patient. But if you're being treated because you'd like to improve your pleasure or enhance your performance, are you a patient? what is a patient? Well, that leads us to the further question, which is, what is an illness? It's not so obvious what it is to be ill. is it to have a disease? Well, not necessarily. There are people who are ill who don't have a disease. we might say that they have a malady of some kind. another terms that's in this constellation of terms, illness, disease. But what is it to be unwell? What is it to have a malady? and, unless you have some kind of, of disease entity are you not a patient if you're seeing if you're seeing a physician and being treated by a physician? it's not so easy to tell. there are of course lots of very comprehensive definitions of health around. the World Health Organization has a definition of heath that basically includes every aspect of one's possible well-being. Physical, mental, social, economic. but many people think that that's just too expansive, and that doesn't really help us understand what the, the needs are for people who are not well. and of course the further question is whether a, a healthcare system, a medical system has any obligations to go beyond just letting people achieve a level of wellness, and beyond that, a level of well being, and beyond that, how far does a healthcare system really

have to go? Does it have to provide lifestyle medications? So, an underlying question here. And we, as we're kind of, knocking around these terms of illness, disease health malady is, well, what is to be normal? is the goal of medicine to help us achieve a level of normalcy and beyond that it's optional? so, cognitive enhancers, lifestyle drugs, are they taking us beyond some threshold of normalcy? But what do we mean by normalcy? So one concept of normalcy, one definition or criterion of normalcy has been to take it sort of at its face as statistical normalcy. What is the norm for some average a mean or a median group of human beings? but of course, that's going to vary depending on your socioeconomic status. In many countries, poverty is highly associated with, with illness. and morbidity and mortality. so is that the average that's appropriate where you live? another way of thinking about normalcy. And I'll just mention very briefly, is some kind of, physiologic normalcy. So when you know something about, you know, what species you're part of in this case you're homo sapiens what is the physiological norm for you as a homo sapien, or what's the, how, how, how good must your vision be to be at the norm? your hearing, your ability to move around, your comfort, your ability to enjoy a modicum of pleasure to live without pain. that sounds pretty good, but it also is a pretty complicated way of defining normalcy. Because really, really don't know what the physiological norm is for human beings. So one way of describing everything that I've talked about in the last five minutes or so from a sociological point of view is that kind of what we've done is we've medicalized what it is to be human. everything that I've said, all the terms that I've used are medical terms. And the whole discussion really has been

about medicine. How much medicine you need to have, what kinds of medicine you need to have, how much is enough. how much takes us beyond some notion of normalcy. We have, to a very great extent, medicalized our lives, especially in the developed world. many people have observed that we're taking our problems, our social problems or economic problems, our moral problems, increasingly finally as medical problems. You know that implies that they can and should be treated. But it's a question worth asking, whether we have medicalized so much of our lives that some of these problems are really being distorted. By seeing them as medical problems. So, but if we if we take the medicalization of many of these problems as a fact. As a given. Then a question that comes up is, who has the authority to treat us for these medical problems? Asked the question before what is a patient. Well what is what is the authority of a doctor? How far does it go? Who has the, has the legitimate social responsibility and obligation to treat us as patients? So, you know, one obvious answer is, of course physicians and other healthcare professionals. and, but does that does that give them any special responsibilities? many people believe that, that there are special responsibilities that accrue to healthcare professionals. and this really goes back to the Hippocratic Oath. So I talked about the Hippocratic Oath in another segment. One of the aspects of the oath that I empathized was that to be a physician, according to this Hippocratic tradition includes the responsibility not to share the secrets of the cult. this, in our modern terms, this is the, the special knowledge of the, or the expert knowledge of the profession. with people who have not taken a certain oath of responsibility.

but, there are very recent critics of that power of the medical fraternity and, you might say, of the medicalization of our social, economic and cultural problems. and these critics, and I'm thinking here especially of the French historian and philosopher Michel Foucault, have argued that what we've really done is we've, we've made so many of our, our problems problems of, of biological power, of what he called biopolitics. that how people function with each other is now part of the, sort of the authority of physicians, of, of the state, of commer, of, of industry, of health insurers, if you like. there's a lot of power in taking care of patients and taking care of what are perceived to be medical problems. there's social power. There's economic power, obviously. there's power that's associated with class differences. And so, lots of different parties in our society, particularly in the modern world as medicine becomes more and more potent, are, are, are competing to have some of this power essentially power over our bodies power over people who are in the role of the patient. and that's not necessarily a matter of, of government power. again it's partly government, that's one of the parties that's contending for control over the implications of a medicalized society. But it's not a, it's also industry, as I've mentioned, and it is the medical profession, and other healthcare professionals. The problem that going beyond therapy involves, the problem of, a problem that's associated with enhancement, as many people would call going beyond, better, being better than well. as one bioethicists has, has put it. Is that it poses a special problem for one part of government, namely regulators. So, in the United States, for example. The Food and Drug Administration has the authority to regulate medications as, as prescription drugs and evaluate them for

their, for their safety and their efficacy. But what if we're talking about drugs or other interventions that are intended to make you better than well. That take you, that, so that it's not just a matter of treating a disease or, or helping you with the malady, or a, a subjective illness of some kind. But actually making you perform better. whether it's a pleasure enhancer or a performance enhancer. What does a regulatory system do with that? Does a regulatory system have the obligation to ensure that it's true? That, this is some stuff that will really give you some kind of greater pleasure, or make you smarter, make you more alert? This is a problem that regulators are wrestling with now. And it's a problem that is going to have to be addressed over the next few years. it's worth noting that drugs that enhance have always been a part of the human experience. One one historian has said, you know, that part of what human beings do is, all the time, is we change our consciousness. we wake up, we go to sleep we eat, we, we engage in reverie and we also, since prehistory, have used all kinds of stimulants and drugs. in fact, the very distinction between what's therapy and what's not therapy, making you well or making you better than well is a modern idea. It really didn't exist traditionally. the therapy, non-therapy distinction we think of now as sort of obvious, but it's not obvious. And then finally there's, there's a question about, as I indicated earlier in this session what are the obligations of government or insurers to take care of us? how much do they have to pay? especially if we're not talking about a traditional therapy. But some kind of improvement. some kind of enhancement over some statistical or physiological norm. What does government owe us? Or what does the state owe us? Or what do third-party

payers or insures owe us? What do our friends and neighbors owe us as they help to support our, our medical care. Do they have to indulge us, some would say, as someone put it, in making us better than well? These are not questions that we've answered yet, but they, but as things get more expensive we are going to need to address them. So in the next segment, I'm going to talk a little bit more about this problem of, problems of enhancement and improving our performance, improving our pleasure. And give an example or two, more, in more detail about how this has become a public issue in the last few years. Thanks.