REVIEW ARTICLE

published: 17 April 2014

SYSTEMS NEUROSCIENCE doi: 10.3389/fnsys.2014.00053

Attitudes toward pharmacological cognitive

enhancement—a review
Kimberly J. Schelle 1 , Nadira Faulmüller 2,3*, Lucius Caviola 2 and Miles Hewstone 2
1
Department of Industrial Design, Eindhoven University of Technology, Eindhoven, Netherlands
2
Department of Experimental Psychology, University of Oxford, Oxford, UK
3
Department of Values, Technology and Innovation, Delft University of Technology, Delft, Netherlands

Edited by: A primary means for the augmentation of cognitive brain functions is “pharmacological
Mikhail Lebedev, Duke University, cognitive enhancement” (PCE). The term usually refers to the off-label use of medical
USA
substances to improve mental performance in healthy individuals. With the final aim to
Reviewed by:
advance the normative debate taking place on that topic, several empirical studies have
Veljko Dubljevic, McGill University,
Canada been conducted to assess the attitudes toward PCE in the public, i.e., in groups outside
Wayne Denis Hall, University of of the academic debate. In this review, we provide an overview of the 40 empirical
Queensland, Australia studies published so far, reporting both their methodology and results. Overall, we find
*Correspondence: that several concerns about the use of PCE are prevalent in the public. These concerns
Nadira Faulmüller, Department of
largely match those discussed in the normative academic debate. We present our
Experimental Psychology, University
of Oxford, 9 South Parks Road, findings structured around the three most common concerns: medical safety, coercion,
Oxford, OX1 3UD, UK and fairness. Fairness is divided into three subthemes: equality of opportunity, honesty,
e-mail: [Link]@ and authenticity. Attitudes regarding some concerns are coherent across studies (e.g.,
[Link]
coercion), whereas for others we find mixed results (e.g., authenticity). Moreover, we
find differences in how specific groups—such as users, nonusers, students, parents,
and health care providers—perceive PCE: a coherent finding is that nonusers display
more concerns regarding medical safety and fairness than users. We discuss potential
psychological explanations for these differences.
Keywords: cognitive enhancement, neuroenhancement, brain function augmentation, medical safety, coercion,
fairness, authenticity, smart drugs

INTRODUCTION categories of cognitive processes: wakefulness, attention and vig-

Brain enhancement is a topic of huge interest in the media and the ilance, memory and learning, and executive functions and infor-
academic literature. An often discussed form of brain enhance- mation processing. The available data about methylphenidate did
ment is pharmacological cognitive enhancement (PCE) which usu- not provide enough information to draw a firm conclusion about
ally refers to the use of certain prescription substances. Schermer the effects of methylphenidate on enhancing or maintaining per-
et al. (2009) define these sorts of enhancements as “pharmaco- formance, although evidence for a positive effect on memory was
logical interventions that are intended to improve certain mental found. An enhancing effect on attention was not verified, con-
functions and that go beyond currently accepted medical indi- flicting with the goal of increasing concentration and alertness
cations” (p. 77). PCE is not only a topic that is debated in that users of enhancement substances often have (Teter et al.,
academia—mainly in neuroscience, law, and ethics—but also a 2005). The aggregated findings of potential enhancing effects of
reality: several surveys show that students, but also other groups modafinil indicate that it improves attention for well-rested indi-
such as academics and surgeons, use substances to enhance viduals. Furthermore, it helps in maintaining a higher degree
their cognitive performance (e.g., Maher, 2008; Smith and Farah, of wakefulness, memory and executive functions over a period
2011; Franke et al., 2013). Examples of seemingly common of sleep deprivation (Repantis et al., 2010). The authors suggest
pharmacological enhancers are methylphenidate (e.g., Ritalin®), that these effects led to a growing popularity of modafinil, and
mixed amphetamine salts (e.g., Aderall®), and modafinil (e.g., strongly recommend a public debate on the ethics of the use of
Provigil®). Originally, the first two were developed as treatment PCE which takes this into account. However, other reviews did
for Attention Deficit Hyperactivity Disorder and the latter as not find any effect or even suggested that the non-cognitive effects
treatment for Narcolepsy, but now they are being used to enhance of the substances, e.g., on confidence and motivation, might be
performance in healthy individuals. responsible for enhanced performance (Farah et al., 2014).
Although there are considerable intra- and interpersonal dif- In the normative debate about whether or not PCE is to be
ferences in the effects of these substances (e.g., Husain and Mehta, endorsed, certain concerns about its use are often raised and have
2011; Van Der Schaaf et al., 2013), average effects have been been discussed by several authors (e.g., Farah et al., 2004; Bostrom
reported. In their overview of findings and meta-analysis of the and Sandberg, 2009; Schermer et al., 2009; Hyman, 2011). In this
effects of methylphenidate and modafinil in healthy individu- review, we focus on three concerns that are most often empha-
als, Repantis et al. (2010) assessed mood, motivation and four sized by the public, but are also discussed in the normative debate.

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

First, the medical safety of the aforementioned substances has on the opinions of groups outside the normative academic debate
been discussed, in particular in terms of short- or long-term side (such as students or physicians) on the use of PCE. We also cross-
effects. A second topic of discussion is coercion, relating to con- checked the reference lists of the studies found this way to identify
cerns about the explicit and implicit pressures that can arise from additional relevant literature matching our inclusion criteria.
the availability of PCE, forcing people to use these substances to Moreover, we checked Google Scholar and asked colleagues pub-
be able to compete, for example at the workplace or in school. lishing in this area to direct us to relevant publications. Overall,
The third concern relates to the fairness of the use of PCE. This this search resulted in 40 publications reporting qualitative or
concern includes several subtopics such as a possible unequal dis- quantitative examinations of attitudes, opinions, and views of the
tribution of access to such enhancers, their use in competitive general public and more often specific sub-populations toward
environments being seen as cheating, and also to what degree PCE, which we included in this review. These 40 publications are
performance brought about under PCE can be seen as authentic. marked with an asterisk in the reference list.
There are good reasons to examine the attitudes of the public Our overarching finding is that in the public several concerns
toward PCE in addition to this normative debate. In their plea about the use of PCE substances are prevalent: they agree on sev-
for the inclusion of public views on developments in biomedicine eral concerns when being asked specifically and raise concerns
and technology, Schicktanz et al. (2012) underline a view already themselves when being asked for their opinion. These concerns
suggested a few years ago by Sarewitz (2010) in a column in widely match the normative debate. Hence, this review is struc-
Nature. They propose three general arguments for the inclusion tured around the common concerns reflected in the academic
of the public in ethical reasoning. First, views and attitudes of the and public debate: (1) medical safety, (2) coercion, and (3) fair-
public can point to remote or emerging moral problems. Second, ness. Each section in this review will be introduced with a short
empirical research can be used to examine premises about human description of the academic debate on the respective concern.
behavior and social consequences of actions that underlie sev- Then, the relevant empirical studies are reported. We also try to
eral applied ethical arguments. Third, research on public opinions pinpoint some shortcomings in the current literature and suggest
can increase the context-sensitivity of ethical reasoning by point- potential paths for future research. Table 1 provides an overview
ing out consequences of concrete decisions in social policy. They of key methodological aspects of all studies reviewed, containing
argue that any bioethical discussion that avoids a confrontation information about the concerns investigated, the research method
with public opinions “not only runs the risk of missing important by which the data were obtained, the country where the study
aspects, ideas, and arguments. It also arouses strong suspicion of took place, and the sample (occupation of participants, sample
being indeed one-sided, biased or ideological—thus illegitimate.” size, sampling method, and response rate).
(Schicktanz et al., 2012, p. 136). Apart from the aforementioned
general arguments to include the public’s attitude in certain MEDICAL SAFETY
bioethical discussions, specific arguments for the case of PCE are The normative debate about the safety of PCE usually focuses
also made. Faulmüller et al. (2013) describe how PCE, as long as on potential trade-offs between benefits and risks. As with all
it is perceived negatively by the public, might give rise to indirect medical procedures, there might be side effects and yet-unknown
psychological costs for users: they might be treated in ways that long-term health risks with substances such as methylphenidate
damage their psychological well-being, for example by a misat- or modafinil (King et al., 2006). Schermer et al. (2009) point out
tribution of their success to the enhancer rather than themselves, that the harm-benefit ratio of PCE deserves special consideration,
or by dehumanization or ostracism. More insight into the pub- as the life-improving benefits might not outweigh the potential
lic’s view can lead to more insight into these potential indirect risks for consumers who use them for enhancement purposes,
psychological costs. In addition, Banjo et al. (2010) argue that instead of the therapeutic purposes for which the substances
physicians are and will be “gatekeepers” in dispensing at least a were originally developed. However, Dubljevic (2013) emphasizes
portion of PCE substances. Although there is discussion on if and the importance of analyzing different substances in a case-by-
how their views might affect social policy or legal regulation on case approach, as some entail greater health and addiction risks
PCE (Delaney and Martin, 2011), PCE is part of their clinical real- than others (Kociancic et al., 2004). Several studies have exam-
ity. Therefore their views can provide specific insights that are of ined people’s health concerns about such cognitive enhancers.
importance to the general debate (Ott et al., 2012). Interestingly both users and nonusers systematically overestimate
The current article is based on an extensive literature search. the cognitive-enhancing effects of PCE (Finger et al., 2013; Ilieva
We used two databases, Web of Science and Scopus, and included et al., 2013), but a sharp discrepancy between their risk estima-
all articles published in English between 1990 and 2014. The tions is revealed. While nonusers generally have strong concerns
search terms we used were [(“cognitive enhancer” OR “cog- regarding the safety of PCE, users show less concern.
nitive enhancement” OR “pharmacological enhancement” OR Nonusers tend to believe that such substances are addictive,
“prescription drug” OR “performance enhancing drug” OR neu- might induce sleep disorders and may even lead to mental
roenhancement OR “human enhancement”) AND (view OR health problems, which was shown in an interview study with 19
perspective OR opinion OR attitude OR judgment OR motive Australian students (Partridge et al., 2013). In two surveys con-
OR justification)] as part of the title, abstract or keyword of the ducted on a UK university campus with a total of 357 students,
text. This search resulted in 447 articles in Web of Science and Scheske and Schnall (2012) observed that moral reservations
4162 articles in Scopus. Based on a careful check of titles and against PCE stem mostly from these safety concerns: the riskier
abstracts, we selected all articles that reported empirical studies the substances, the more student respondents morally object to

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

Table 1 | Overview of the empirical studies discussed in this review.

Authors Country Occupation of Sampling method Research Response Sample Concerns

participants method rate size

Aikins, 2011 USA University students Purposive sampling Semi-structured n/a 12 Safety, fairness
interview

Asscher and The General public Purposive sampling Focus groups n/a 37 Safety
Schermer, 2013 Netherlands

Ball and Canada Parents Purposive sampling Semi-structured n/a 12 Safety

Wolbring, 2014 interview

Banjo et al., 2010 USA and Physicians Convenience Web-based n/a 212 Safety,
Canada sampling survey coercion,
Fairness

Bell et al., 2013 Australia University students Convenience Interview n/a 19 Safety,
sampling coercion

Bergström and Sweden General public Random sampling Paper and pencil 52% 517 Safety
Lynöe, 2008 questionnaire
Physicians 39% 108

Bossaer et al., USA University students All students at one Web-based 59.9% 372 Safety, fairness
2013 university invited survey

Desantis and USA University students Convenience Interview n/a 175 Safety
Hane, 2010 sampling

Dodge et al., USA University students All students at one Web-based 37% ±1200 Fairness
2012 university invited survey

Dubljević et al., Germany University students Three stage cluster Web-based First 5882 Fairness
2013* sampling survey wave
(universities, 53.5%
disciplines, students)
Second 3486
wave
69.1%

Eickenhorst Germany University students Convenience Web-based n/a 1218 Safety

et al., 2012 sampling survey
University graduates 106

European Belgium, General public Stratified random Citizen’s n/a 126 Coercion
Citizens Panel, Denmark, sampling (age, deliberation
2006 France, profession, gender)
Germany,
Greece,
Hungary,
Italy, the
Netherlands,
UK

Fitz et al., 2013 USA and General public Convenience Web-based n/a 4011 Safety,
Canada sampling, Amazon’s survey coercion,
Mechanical Turk fairness
recruitment

(Continued)

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

Table 1 | Continued

Authors Country Occupation of Sampling method Research Response Sample Concerns

participants method rate size

Forlini and Canada University students Purposive sampling Focus groups n/a 29 Coercion
Racine, 2009
Parents 21

Health care providers 15

Forlini and Canada University students Purposive sampling Focus groups n/a 29 Safety,
Racine, 2012a coercion,
fairness
Parents 21

Health care providers 15

Forlini and Canada University students Purposive sampling Focus groups n/a 29 Safety, fairness
Racine, 2012b
Parents 21

Health care providers 15

Franke et al., Germany High school students All students at 12 Paper and pencil 83% 1035 Safety,
2012a* public grammar and questionnaire coercion,
vocational schools, fairness
and students of
three departments of
one university invited
University students 512

Franke et al., Germany University students Convenience Interview n/a 22 Safety,

2012b sampling coercion,
fairness

Franke et al., Germany Physicians All primary care Paper and pencil 30.2% 832 Safety
2014 physicians in one questionnaire
state invited

Hotze et al., 2011 USA Physicians Random sampling Paper and pencil 46.6% 633 Fairness
questionnaire

Judson and USA University students All students at two Paper and pencil 10% 333 Safety
Langdon, 2009 colleges invited questionnaire

Kudlow et al., Canada University students All medical students Web-based 50% 326 Safety
2013 at one medical survey
school invited

Maier et al., Switzerland University students All students at three Web-based 22.3% 6275 Coercion
2013 educational survey
institutions invited

Maslen et al., Germany University students Convenience Paper and pencil n/a 80 Coercion
in press sampling questionnaire

Mazanov et al., Australian University students Convenience Web-based n/a 1729 General,
2013 sampling survey fairness

Ott and Switzerland University students Convenience Web-based n/a 1765 Safety, fairness
Biller-Andorno, sampling survey and
2013 separate paper
and pencil
questionnaire

(Continued)

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

Table 1 | Continued

Authors Country Occupation of Sampling method Research Response Sample Concerns

participants method rate size

Ott et al., 2012 Switzerland Physicians Stratified random Paper and pencil 23.9% 379 Safety
sampling (profession, questionnaire
gender, years of
training, language)

Partridge et al., Australia General public Random sampling Telephone 31.9% 1265 General
2012 interview

Partridge et al., Australia University students Convenience Interview n/a 19 Safety

2013 sampling

Riis et al., 2008 USA University students No information Web-based n/a 357 Fairness
provided survey

Sabini and USA University students Convenience Paper and pencil n/a 185 Fairness
Monterosso, sampling questionnaire
2005

Santoni de Sio United University students Convenience Paper and pencil n/a 102 Safety, fairness
et al., in press Kingdom sampling questionnaire

Sattler et al., Germany University students Three stage cluster Web-based 87.1% 1852 Safety, fairness
2013a* sampling survey
(universities,
disciplines, students)

(Sattler et al., Germany University teachers Three stage cluster Web-based 33.5% 1402 Safety
2013b)* sampling survey
(universities,
disciplines,
students/teachers)
University students 69.1% 3486

Sattler et al., Germany University students Three stage cluster Web-based 69.1% 3486 Safety,
2014* sampling survey coercion,
(universities, fairness
disciplines,
students); only
second time wave

Sattler and Germany University students Three stage cluster Web-based First 5882 Safety
Wiegel, 2013* sampling survey wave
(universities, 53.5%
disciplines,
students); only
second time wave
Second 3486
wave
69.1%

Scheske and UK University students Convenience Paper and pencil n/a 50 Safety, fairness
Schnall, 2012 sampling, two questionnaire
studies - two
samples
306

Schildmann Germany University students No information Survey n/a 1026 Coercion,

et al., 2013 provided fairness

(Continued)

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

Table 1 | Continued

Authors Country Occupation of Sampling method Research Response Sample Concerns

participants method rate size

Schuijff and The All Purposive sampling Focus groups n/a 38 Safety,
Brom, 2013 Netherlands coercion,
fairness

Sweeney, 2010 USA University students Convenience Paper and pencil n/a 100 Safety, fairness
sampling questionnaire

Convenience sampling and purposive sampling require no random selection of participants, whereas random sampling, stratified random sampling and cluster
sampling do. Purposive sampling requires obtaining a sample of people who meet a predetermined criterion, whereas convenience sampling does not. For stratified
random sampling, a population is divided in strata (subgroups) from which participants are randomly selected to make sure all strata are represented in the sample
in proportion to their prevalence in the population. Cluster sampling requires a list of clusters, e.g., disciplines in a university, from which a few clusters are randomly
chosen. Instead of randomly selecting participants from a list of potential participants, e.g., all students of the university, every member of the selected cluster is
invited to participate (Cozby, 2009).
*The authors explicitly state that N is not equal for each analysis due to missing data or specific criteria employed.

their non-medical use. Similarly, in a survey involving 102 UK all parents unanimously agreed that medical safety has to be
Science students, Santoni de Sio et al. (in press) found that the insured in order to administer PCE to their children.
concern against enhancement use that was raised most often by Sattler and Wiegel (2013) provided the first evidence on the
respondents related to potential unintended side-effects. influence of the perceived severity of side effects and risk atti-
A plausible consequence is that students are less willing to tudes on actual PCE use. In a large- scale online survey with
engage in PCE the higher the severity and risk of the resulting 5882, in a first wave, and 3486 respondents, in a second wave, a
health issues are perceived to be. This was shown in two German lower proneness to risk and an expectation of more severe drug-
factorial design online surveys based on a large pool of vignettes related side effects were associated with more PCE use at the first
with a sample of 1852 students in the first study (Sattler et al., time point and increased use of PCE over a 6-months period.
2013a) and 3486 students and 1402 university teachers in the sec- However, other results in the second wave of the same project did
ond study (Sattler et al., 2013b; these are results of the second not show the relation between the expected severity of side effects
wave of a biannual project; also see Sattler and Wiegel, 2013 and or risk attitudes and willingness to use PCE (Sattler et al., 2014).
Dubljević et al., 2013 for findings on the first and second wave, The authors did, though, find in the second wave that a higher
and (Sattler et al., 2014) for other results on the second wave). expected likelihood of side effects decreased the willingness to use
Moreover, Franke et al. (2012a) showed in an extensive paper- PCE.
and-pencil questionnaire study with a sample of 1547 German Other findings suggest that natural remedies are perceived
students that the majority would consider taking PCE substances as less harmful than PCE substances, as shown in a question-
only if their safety could be assured. naire study involving the Swedish general public and physicians
The relation between willingness to use PCE and the perceived with a sample size of 625 in total (Bergström and Lynöe, 2008).
risk of PCE might also be an explanation for the results from a Furthermore, people morally object more to the application of
focus group study on several human enhancement technologies PCE substances if they are artificial rather than natural, and
conducted with 38 Dutch participants divided into five groups if they are taken in the form of injections rather than pills
(Schuijff and Brom, 2013). (A focus group study is a qualitative (Scheske and Schnall, 2012). Focus group participants in the
research technique in which a group of participants discuss their Netherlands referred to natural remedies, placebo, and psycho-
opinions on a given topic.) After more information on the effects logical treatment as alternatives to a specific example of PCE
and risks of using methylphenidate as an enhancer was provided, (taking β-blockers during a driving test; Asscher and Schermer,
fewer participants stated they would consider using the substance 2013). However, these results may depend on the familiarity of
for enhancement purposes than before receiving the information. the sample with medical substances. An online survey among 326
Participants in this study were not familiar with the concept of Canadian medical students showed that there were no significant
human enhancement, in contrast to participants in most of the differences between attitudes toward pharmacological or natural
other studies, and therefore might have underestimated the risks supplements for cognitive enhancement (Kudlow et al., 2013).
accompanying the use of PCE. In another Dutch focus group Furthermore, 212 US American and Canadian physicians,
study with 37 participants divided into five groups, several exam- reported in an online survey, being less comfortable prescribing
ples of the use of medical means to fulfill non-medical wishes PCE substances for non-medical use to young adults, compared
were investigated. An example related to PCE, taking β-blockers to older patients (Banjo et al., 2010). Franke et al. (2014) con-
during a driving test, raised several concerns about medical risks firmed these findings in a paper and pencil questionnaire study
(Asscher and Schermer, 2013). In a semi-structured interview among 832 German physicians. In both studies, physicians wor-
study with twelve Canadian parents of either cognitively disabled ried about misuse and deemed PCE for young people to be
or non-disabled children, Ball and Wolbring (2014) observed that unnecessary. Yet, this applied less to the treatment (i.e., medical

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

use) of older patients. Consistent with these findings, an exper- (Partridge et al., 2012). Also users of PCE among a group of
imental vignette study conducted online with 4011 respondents Canadian medical students tended to have more favorable atti-
found that the US American and Canadian public is more toler- tudes toward PCE than nonusers (Kudlow et al., 2013). Lastly, a
ant of side effects when they can be seen as the result of necessary survey of 1729 students from Australian universities revealed dif-
therapy instead of enhancement (Fitz et al., 2013). This touches ferences in attitudes between users and nonusers of PCE, with
upon a big debate in medical ethics about the distinction between users more often finding the use of study drugs “moral” than
treatment and enhancement, since this is not a distinction based nonusers (Mazanov et al., 2013). The latter three studies did not
on biological facts, but, rather, reflecting subjective valuation specifically present the reason why respondents had a certain atti-
(Parens, 1998; Daniels, 2000; Hyman, 2011). This is also reflected tude toward PCE, and thus their opinions might not be related to
in a survey by Ott et al. (2012), who concluded that subjective medical safety. Still, these results are in line with a common find-
suffering is taken into account as a criterion for disease. From ing in drug epidemiology, revealing that positive attitudes toward
the respondents, 379 Swiss general practitioners and psychia- a drug, in particular low perceived risk, correlate with its use (e.g.,
trists, 88% reported being influenced by the degree of subjective Bachman et al., 1998; Bavarian et al., 2013; Cabriales et al., 2013).
suffering in prescribing an enhancer in four different scenarios. In addition, users justify their practice and underestimate
When asked if they would prescribe a PCE substance if a stu- potential health risks for themselves and for others as shown in an
dent requested a prescription to stay awake to study more, only interview-based survey with 175 US American students (Desantis
15% confirmed without any doubt, although 54% would pre- and Hane, 2010). Conversely, Franke et al. (2012a) found that
scribe if there were no therapeutic alternative. Around half of the users and nonusers estimate addictive risks similarly, perhaps
respondents reported being confronted in their practice with such because there is a greater likelihood of substance dependency for
requests for prescriptions. users (Kroutil et al., 2006). However, Franke et al. (2012a) did not
In contrast to these consistent findings on nonusers, users of specifically test for PCE dependency in their study. In the above-
PCE differ in their estimation of the safety of PCE substances. mentioned study by Desantis and Hane (2010), it was revealed
In an online survey with 1324 German students, users tended that users argue for the substances’ safety and downplay poten-
to rate the health consequences of PCE as less dangerous than tial health risks by contrasting PCE to street-drugs (e.g., cocaine,
nonusers did (Eickenhorst et al., 2012). This could be explained heroin, etc.) and by pointing toward their acceptance within the
by users’ higher ratings of willingness to take risks, found in a medical establishment. This relates to the observation that stu-
large-scale online survey involving 1765 Swiss students (Ott and dents who believe that they know enough in order to safely use
Biller-Andorno, 2013). Moreover, fewer individuals (63.9%) from PCE are more likely to state that PCE is harmless (Sweeney, 2010).
this latter survey’s “user group” of 108 students reported worry- The fact that users tend to estimate PCE usage as harmless might
ing about side effects than individuals from the “nonuser group” explain why they find its application to be morally and socially
of 1689 students (81.9%). Similarly, in a semi-structured inter- acceptable (Desantis and Hane, 2010).
view study with 12 US American students who were illicitly or Hence, there is a general discrepancy between the views of
licitly using PCE, most participants believed that the benefits users and nonusers with regard to the associated health risks of
of PCE outweighed the potential negative side effects (Aikins, PCE and its moral acceptance, with users being less concerned
2011). Another study with 333 US American students revealed than nonusers.
that students who were illicitly using PCE had even more pos-
itive attitudes to the use of PCE with regard to medical safety COERCION
issues compared to licit users (Judson and Langdon, 2009). In The question of coercion relates to autonomy, i.e. the freedom to
another interview study with 22 German students who used decide about one’s personal life, and is a central issue in the nor-
both caffeine and PCE, participants saw differences between the mative debate on PCE. A main concern is that people are being
two forms of enhancement: in particular they estimated both pressured or even coerced into enhancing themselves. This might
the desired effects and the negative side effects as more pro- happen either indirectly in the form of peer pressure (Warren
nounced in the case of PCE (Franke et al., 2012b). Also, Sweeney et al., 2009), or potentially directly in certain workplaces with long
(2010) presents in her thesis results of a campus survey with a working hours and high demands on cognitive functioning, such
sample of 100 US American students, which demonstrate that as in the military or in surgery (Schoomaker, 2007; Maslen et al.,
students who are illicitly using cognitive enhancers seem to be in press). While opponents of enhancement consider it a “threat
more likely than nonusers to believe that the substances are to the responsibility one bears for one’s own life” (Habermas,
harmless. 2003, p. 61), proponents instead focus on its advantages. They
The aforementioned findings concerning differences between point out that PCE in particular entails the possibility of enhanc-
users and nonusers in their estimation of risks and harmful- ing autonomy itself by increasing the reasoning abilities required
ness might also explain the large difference between the attitudes to engage in such autonomous decisions (Schaefer et al., 2013).
of users and nonusers found in other studies. A study on atti- The participants in Schuijff and Brom’s (2013) focus group
tudes toward the acceptableness of PCE amongst 1265 members study indicated implicit peer pressure and explicit demand by
of the general public in Australia found that respondents who employers to use human enhancement technologies to be a major
were familiar with PCE—either by using it themselves or by concern for them. Maslen et al. (in press) found in a survey of
knowing somebody who used PCE—were twice as likely to find 80 UK students clear and strong objection against the idea that
PCE acceptable than respondents who were not familiar with it people in professions with high responsibility, such as pilots and

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

physicians, might even have a moral obligation to enhance their that even though a qualitative approach as used by Forlini and
performance, with only one respondent agreeing to such an obli- Racine (2009) can reveal aspects that might stay undiscovered in
gation and 44% completely disagreeing. Two other surveys among quantitative approaches like surveys, the small sample size might
German students found that the majority of students did not limit the generalizability of the findings. Going beyond method-
approve of PCE in jobs with high responsibilities: in one survey ology, we might speculate that it is not other people using PCE
only 26% of the 1026 respondents approved of the use of PCE per se, but other people performing better, that puts pressure on
in highly responsible jobs (Schildmann et al., 2013), the second students and leads them to consider taking such substances. In
found that approximate 20% of their 1547 respondents approved general, student participants in Forlini and Racine’s (2009) focus
the use of PCE for individuals with high responsibility (Franke groups viewed PCE as a personal lifestyle choice and emphasized
et al., 2012a). the importance of personal integrity, i.e., they accepted the use
Forlini and Racine (2009) conducted one of the (very few) of PCE conditional on the fact that one remains faithful to one’s
studies investigating people’s attitudes on autonomy and coer- personal values. At the same time, they recognized the difficulty
cion specifically with regards to PCE, again with the use of of that endeavor when social pressure is high and when absti-
focus groups. Their participants, 65 Canadians assigned to one nence could lead to personal disadvantage. Parents of university
of nine groups consisting of either students, parents, or health- students, on the other hand, maintained a paternalistic view: stu-
care providers, agreed that PCE should be a matter of personal dents should be informed about cognitive enhancement, and, as
choice. This seems in line with one of the recommendations of a consequence, they should be held responsible and accountable
a “European citizens’ panel” held in 2005 and 2006, a citizens’ for the decision to engage in PCE.
deliberation on brain science involving 126 individuals from nine Thus, people consider the role of peer pressure as problematic
European countries. (A citizen’s deliberation is a form of pub- and agree on the importance of deciding autonomously whether
lic participation in consultation about science, but can be less to engage in PCE. However, since the few studies reported here
structured than a focus group study because groups can change reveal mixed results, more research is needed to investigate the
during the deliberation.) One of the topics touched upon briefly topic in greater depth.
was human enhancement. The participants’ highest ranked rec-
ommendation was that people should be given the right to take FAIRNESS
“whatever drug they want,” but enough information about the The normative debate around the fairness of PCE is perhaps the
effects and dangers should be available; however, they did not least clearly defined. The term “fairness” seems to raise different
support use of PCE in situations in which people have to pass distinct concepts in the lay mind, and thus creates a difficulty
exams (European Citizens Panel, 2006). in comparing different studies that ask for opinions on the fair-
Participants in Forlini and Racine’s (2009) study held the ness of PCE use without defining what is meant by “fair.” Overall,
descriptive view that users are generally deciding to take such fairness related concerns seem to play an important role in the
substances as a result of a voluntary decision. At the same time, public, since they have been the second most common argument,
however, they believed that this decision can be influenced by per- after unintended side effects, against the use of enhancement
ceived social pressure or by competitive environments, such as raised by participants in Santoni de Sio et al.’s (in press) sur-
academia or the job market, where people are striving for suc- vey. Forlini and Racine’s (2012a also c.f. Forlini and Racine,
cess and feel they have to perform better than average. Health 2009) focus-group study explored lay statements about fairness
care providers amongst the participants admitted that students of PCE in greater detail. They developed a model to describe
who don’t take enhancers may be disadvantaged because demands three different subthemes: they suggest that judgments of fair-
are getting higher and PCE is becoming more prevalent. They ness can (apart from external factors like legislation) be defined
regarded peer pressure as an important contributing factor to the by a relationship between equality of opportunity, honesty, and
perceived need to take cognitive enhancers. Parents, in contrast, authenticity. Participants who valued the equality of opportunity
were aware of the pressure being put on students and conse- described the importance of an equal distribution of opportuni-
quently felt worry and sadness. They feared that the use of PCE ties to obtain PCE substances and opportunities deriving from
may become a new standard. their use. Honesty and authenticity are both related to effort
However, peer pressure seems to be a more complex phe- that has to be invested to achieve a certain task. The underlying
nomenon than one might assume. Sattler et al. (2014) show that assumption is that when high performance is achieved with less
willingness to take PCE drugs does not increase when others effort—as might be the case when PCE substances are taken—
encourage it, but it decreases when disapproval of the use of PCE this might be less fair compared to performance that is achieved
by others rises. Furthermore, on the one hand, Forlini and Racine with substantial effort. Honesty relates to the social aspect of this
(2009) observe the desire of students not to be at a disadvantage, assumption and reflects the effect of PCE use on other individ-
while on the other hand, less than 10% of 1547 German students uals, for example in a competitive environment where PCE use
stated in a survey by Franke et al. (2012a) that they would use might be seen as cheating. Authenticity relates to the individ-
PCE if others did so. In an online study amongst 6275 Swiss stu- ual PCE user and questions whether his/her performance under
dents less than 3% agreed that other people’s use of substances PCE, often seen as a situation in which effort is discounted, is
would justify the use of PCE, compared to over 66% who agreed an authentic performance. It is based on the underlying belief
that increased learning would justify the use (Maier et al., 2013). that putting in effort shapes the experience of an individual and
One methodological reason for these diverging findings might be thus affects a “future” individual that does not gain the same

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

experience while using PCE. Although the above separation of (2005) study endorsed the so-called “interaction view” (p. 91):
concepts is too coarse to fully reflect the depth of the academic their judgments of fairness depended on the group that was
normative debate, the concerns of the public can be grouped affected by the drug. Although their fairness ratings of PCE
around these subthemes of fairness. use were always close to or lower than the midpoint of the
scale—thus generally regarding it as rather unfair—respondents
EQUALITY OF OPPORTUNITY believed the use by the worst performing 10% of students
First, we discuss equality of opportunity, the fear that inequality to be fairer than the use by everybody or the top 10%. The
in access to enhancement substances might increase inequalities “interaction view” corresponds to what John Rawls (1971,
in society. Farah et al. (2004) describe how certain groups might 1985) calls the “difference principle”: inequality is acceptable
experience cost barriers and social barriers to access PCE. (In this only if the current situation for those least advantaged is
section, we do not consider concerns about restrictions of free- improved.
dom to follow personal preferences, as these are discussed in the A survey amongst 1026 German students demonstrated that
previous section about coercion). Equality of opportunity is also 27% of the respondents approved the use of PCE by worse
referred to as distributive fairness (e.g., Scheske and Schnall, 2012), performing classmates, while 57% approved the use for elderly
distributive justice (Farah et al., 2004), or the concern of inequal- with declining cognitive performance (Schildmann et al., 2013).
ity (e.g., Bostrom and Sandberg, 2009). Note that the notion of Correspondingly, over a quarter of the respondents of another
equality of opportunity relates to a certain underlying theory of study among German students reported that classmates with
justice (cf. Rawls, 1971), which can be contrasted, for example, low academic performance should be allowed to use PCE, while
to the notion of equality of outcome. However, these underly- 50% indicated that the use of PCE by cognitively impaired
ing theories are not distinguished yet in empirical research on the elderly should be allowed (Franke et al., 2012a). The percent-
public’s opinions about PCE. age of respondents who endorsed the use of PCE by classmates
Although healthcare providers, students and parents who par- with low academic performance was higher among PCE users
ticipated in the focus group study by Forlini and Racine (2012a) than nonusers. It is clear that although the interaction view is
believed that, currently, everybody who wanted could find PCE endorsed, previous performance is of less influence on judgments
substances one way or another, they did emphasize the impor- of fairness of the use of PCE than age. However, this is perhaps
tance of the value of equality of opportunity as part of their because the samples are both young students who are in com-
judgment on the fairness of the use of PCE. Correspondingly, in petition with other young students, so that age and performance
survey research by Sattler et al. (2013a) amongst 1852 respon- variables could be said to be confounded in the sample. Future
dents, a lower score on both willingness-to-use a PCE and studies need to investigate the attitudes of young students in com-
moral acceptability of PCE substances was reported when judg- petition with elderly students, and compare elderly students with
ing an imaginary situation where no other students take this elderly non-students, so that attitudes toward these factors could
PCE substance, compared to situations in which half of the be separated. Sabini and Monterosso (2005) explain the interac-
other students or all fellow students were taking the PCE sub- tion view by arguing that a substance that would affect the worst
stance. Possibly, they read the “no other student” situation as performing 10% only can better be seen as a normalizer instead
one where there is inequality in opportunity with them hav- of an enhancer, suggesting that in this case it might be closer to a
ing, and other students not having, access and found this to be treatment than to an enhancement. If this explanation is correct,
morally unacceptable. However, Sattler et al.’s (2013a) finding it would seem that both the acceptance of side effects as well as
could also point to the experience of a “social norm,” following the acceptance of a certain unequal distribution is greater in the
from the prevalence of use that influences the judgment of moral case of a treatment compared to enhancement.
acceptability. In general, healthcare providers, students, and parents seem to
In a survey, Hotze et al. (2011) presented 633 US American agree that an unequal distribution of PCE is unfair, if the unequal
general practitioners with two statements related to this topic: distribution is related to factors that are changeable, such as
a slight majority agreed that society should prevent economic wealth. If the unequal distribution exists due to biological disposi-
advantages turning into biological advantages (57%), and that tions, such as having a low attention span, an unequal distribution
everyone should have equal access to medical enhancers (55%). is seen as less relevant to moral judgments. This is related to the
Scheske and Schnall (2012) showed that the use of PCE sub- distinction between treatment and enhancement, in which the
stances is perceived as more wrong if not everybody can former is generally believed to be seen as more acceptable (Parens,
afford them, compared to situations in which everybody can. 1998; Daniels, 2000; Hyman, 2011). Users find it more acceptable
Fitz et al. (2013) investigated fairness by using the contrastive than nonusers that fellow students with low academic perfor-
vignette technique online. Their 4011 respondents, recruited via mance use PCE, but research investigating the reasons for these
Amazon’s Mechanical Turk, were randomly assigned to one of diverging views of users and nonusers is still lacking.
22 different vignettes that described the use of PCE diverg-
ing in terms of alleged safety, societal and peer pressure, fair- HONESTY
ness and authenticity. Respondents saw it as less fair if a stu- Honesty relates to the question of whether the use of PCE might
dent obtained an enhancer with the help of money given by give a user an unfair advantage over people who do not use PCE,
his parents rather than with money earned by own work. and thus might need to exert more effort to achieve the same
The 185 US American respondents in Sabini and Monterosso’s result. Scheske and Schnall (2012) refer to honesty as competitive

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

fairness and Bostrom and Sandberg (2009) discuss it in relation reduction of effort for the user of PCE in comparison to a nonuser
to cheating. Using an example and taking a normative stance, resulted in respondents judging PCE as less fair.
Bostrom and Sandberg (2009) describe how goals and rules define Qualitative studies provide a more elaborate but also more
whether an act qualifies as cheating: if the primary goal of school- ambiguous perspective on honesty in relation to PCE. In an inter-
ing is acquiring knowledge, PCE might be legitimate. In the case view study amongst 19 Australian students by Bell et al. (2013
of a competition for grades or admission, however, PCE could also c.f. Partridge et al., 2013) fairness appeared at the top of the
be seen as cheating if it were against the rules or if access were list of concerns mentioned. More than half of the participants
unequally distributed. described PCE as a form of cheating, while most of the others
Quantitative accounts of the public’s opinion on honesty explicitly reported that they did not find it unfair in compar-
related to PCE use can be found in several studies. Students ison to other available methods for performance improvement
of a highly competitive UK university deemed the competitive (e.g., coffee). In contrast to coffee, focus group participants saw
advantage PCE can give as one of the most important con- PCE as a form of cheating similar to the use of steroids (Forlini
cerns regarding its use: an advantage due to PCE use was found and Racine, 2012b). Also, participants showed dissent and inde-
most morally wrong when no other competitors were taking the cision about whether PCE use should be seen as cheating or not
substance, relating competitive to distributive fairness and peer (Forlini and Racine, 2012a). Each subgroup of students, parents,
pressure (Scheske and Schnall, 2012). Moreover, an online survey and health care providers included some individuals who saw
by Bossaer et al. (2013) demonstrated that 60% of the 372 student PCE as an unfair shortcut, putting others at a disadvantage, but
respondents agreed that PCE provides users with an unfair advan- also individuals who considered PCE a study tool like any other.
tage over other students. An almost identical amount of just over To summarize, a little over half of the public believes that the
half of the respondents (56%) believed that PCE use for study use of PCE provides an unfair advantage to users, a situation that
purposes could be seen as academic dishonesty. In a large-scale is seen as cheating, especially in highly competitive environments.
online survey, with respectively 5882 and 3486 participants in the Nonusers provide lower ratings of honesty than users in quantita-
first and second wave, (Dubljević et al., 2013) found that German tive studies. In general there seems to be dissent on whether PCE
students deem the use of PCE with the intention to increase study qualifies as cheating or not. Qualitative studies give more insight
performance to be morally less acceptable than traditional forms into the different perspectives on this question.
of academic misconduct, such as cheating in exams, fabrication,
or plagiarism. Schildmann et al. (2013) reported that half of the AUTHENTICITY
respondents of their questionnaire study thought the use of PCE In the normative debate, critics of PCE argue that users, com-
by others was unfair, another quarter was unsure of their thoughts pared with nonusers, of enhancement substances experience the
about the statement, and only a quarter “rather” or “absolutely” value of exerting effort on a task less. This makes activities less
agreed that the use of PCE by others was fair. Over half of the meaningful and facilitates fewer experiences of self-development
respondents in Franke et al. (2012a) indicated in a questionnaire (see Schermer, 2008, for an analysis of this argument). Part of
that they found PCE fair “under no circumstances” or “proba- the debate therefore relates to authentic performance, for which
bly not.” This percentage was higher among females and among effort is seen as a necessary condition (e.g., President’s Council
nonusers. Although exact percentages are not provided, Sweeney on Bioethics, 2003). Goodman (2010) specifies that this is true
(2010) also discusses a survey amongst 100 students in which for what he calls process goods, for which the activity itself is seen
nonusers felt more troubled than users by academic advantages as central. For so-called outcome goods, however, for which the
obtained by PCE. This difference between users and nonusers was result of an activity counts, effort is less relevant.
also found in the online survey by Ott and Biller-Andorno (2013). We can apply the distinction between process goods and
They show that a little over 40% of nonusers agree that with using outcome goods to the list of 19 traits rated by 357 respon-
PCE, one would be betraying others who do not use PCE, while dents in an online study by Riis et al. (2008). For each trait
less than 20% of users agree to this statement. An online study they had to rate their willingness to enhance it using pharma-
with 1200 male US American student participants revealed that cological means, if they could. Outcome related traits, such as
the misuse of performance enhancement substances in the sport- memory, received higher scores on willingness-to-enhance than
ing domain received a higher rating on a scale that measured the more process related traits, such as mood and social comfort.
degree of cheating than the use of PCE in academia (Dodge et al., These higher ratings for what we deem outcome related traits
2012). might be explained by respondents valuing the notion of effort.
As described above, Fitz et al. (2013) showed that when obtain- Furthermore, respondents were less willing to enhance traits that
ing PCE takes less effort, it is seen as more unfair. This was were rated as more fundamental to the self, such as kindness and
reflected in reduced fairness ratings in a scenario in which one empathy.
individual could use PCE and another could not. The effort Participants in the focus group study by Forlini and Racine
needed to obtain PCE was manipulated, as well as a second vari- (2012a) explicitly related effort to judgments of the fairness of
able, that of the effect of the PCE as either reducing the effort PCE. Students, parents, and healthcare providers commented
needed to study or increasing the number of hours that one could on effort and authenticity. They displayed both positive (non-
study for. The combination of diminished effort in obtainment problematizing) and negative (problematizing) views toward PCE
and reduced study effort produced the lowest ratings of fair- in relation to effort and authenticity in equal proportions, as can
ness. Thus, any variation of the description that would result in a be seen in the following examples. Participants of each target

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

group (students, parents, and healthcare providers) noted that et al., 2009). The findings we present are divided between three
even with the use of PCE, effort still had to be put in to complete concerns regarding PCE use which are common in both the
certain tasks. However, participants also discussed how enhance- ethical and lay debate: medical safety, coercion, and fairness.
ment may compromise certain social and personal values that Several studies have shown that medical safety is regarded as
shape an individual’s behavior. Also some of the student par- central by nonusers of PCE, and insecurity about it provides a
ticipants in the interview study by Bell et al. (2013) described reason for them to refuse the use of PCE. Related to this concern
PCE as a quick fix rather than a true reflection of an individ- are findings that point toward a preference for natural over artifi-
ual’s abilities, while other participants neither reported effort cial enhancers. A similar preference can be seen for interventions
nor authenticity as being corrupted by the use of PCE. Two that might be closer to treatment than to enhancement. Users,
thirds of the student respondents in the survey by Schildmann on the other hand, do not display these preferences and indicate
et al. (2013) agreed that performances done with PCE were conflicting results on judgments of (subjective) health risks asso-
“less commendable than comparable performances that are done ciated with PCE. They are concerned about addiction, but do not
without these substances” (p. 25). In addition, 63% of the 644 worry about other health risks, and deem PCE more often harm-
physicians who completed the survey by Hotze et al. (2011) less than nonusers do. A more convergent view can be found on
viewed PCE as a threat to the value of human achievement. the theme of coercion. Different subgroups agree that PCE should
Moreover, an online survey by Banjo et al. (2010) showed that be a matter of personal choice. They believe that decisions con-
the respondents, 212 physicians, ranked “PCE undermines the cerning use are, in general, made voluntarily, although they can be
values of personal effort” as the fourth most important rea- influenced by perceived social pressure or by competitive environ-
son (of 13 presented) to feel uncomfortable about prescrib- ments. It is shown that peer pressure is a complex phenomenon,
ing PCE to non-elderly people. However, an online survey as students might not always be influenced by other people’s PCE
among 1729 Australian students showed that users of prescrip- use itself, but only when these others achieve a higher perfor-
tion amphetamines had fewer concerns regarding the integrity of mance compared to their own. However, only a few studies have
authentic and moral actions than did nonusers (Mazanov et al., investigated coercion to date and we call for future research to
2013). fill this gap. Finally, we discussed fairness, divided into three sub-
Finally, in their experimental vignette study Fitz et al. (2013) themes: equality of opportunity, honesty, and authenticity. An
found that respondents rated an individual’s performance as sig- unequal distribution of PCE substances that might develop due
nificantly less authentic when PCE was used, compared to when it to changeable factors—such as wealth—is seen as unfair, while
was not used. However, this opinion did not completely transfer an unequal distribution due to biological dispositions—such as a
to judgments of worthiness for a promotion when the character low attention span—is seen as less relevant to judgments of fair-
would be assigned a new project in his job. Respondents judged ness. This might relate to a general finding that treatments are
a PCE user as significantly more worthy when successful without seen as more acceptable than enhancements. The public’s opin-
enhancement compared to with enhancement, but they also indi- ion on the subthemes of honesty and authenticity shows a more
cated that people who succeeded with the help of PCE were more complex pattern. Nonusers believe more often than users that the
worthy of promotion than people who did not use PCE and failed. use of PCE provides an unfair advantage, although in general
To summarize, in general people are more likely to enhance only half of the public raises concerns about this topic of hon-
outcome related traits than process related traits. However, in esty and cheating. Several studies show that around the theme of
direct discussions about effort and authenticity in relation to fair- authenticity both problematizing and non-problematizing views
ness, individuals display divergent opinions on the importance of on PCE arise in equal proportions. While some respondents indi-
these topics. The proportion of people who believe effort is dis- cate that “the work has still to be done” even when PCE is used,
counted and authenticity violated when using PCE is a little over others believe that PCE is a quick fix and undermines an authentic
half of the respondents in most studies. This implies that little performance.
less than half of the public is not that concerned about effort and One important distinction within the public can be found
authenticity in relation to PCE. One reason that is given is that between users and nonusers, who tend to differ in their perspec-
effort still has to be invested to achieve certain goals, even when tives on the medical safety and subthemes of the fairness of PCE:
PCE is used. while users generally deem PCE to be safe and fair, nonusers
do not. These results imply that users are either more willing
CONCLUSION to engage in PCE because of their positive attitude toward it,
This review provides an overview of 40 studies on the public’s or that they adopted their positive attitude as a result of per-
opinion about PCE. Our main finding is that in groups outside sonal usage. In either case, the differences in users’ and nonusers’
the normative academic debate several concerns about the use attitudes toward PCE might be driven by cognitive biases. It is
of pharmacological substances for performance enhancement are possible, for example, that nonusers display a more negative view
either raised or endorsed. These concerns that are discussed in toward PCE because they experience the so-called status quo
the current review of research on opinions about PCE widely bias, which describes the irrational preference for an option only
match the normative debate. These similarities between the pub- because it preserves the current state of affairs (Kahneman and
lic’s opinion and the normative debate are also found in studies Tversky, 2000). As currently PCE use is not seen as a common
on other ethical issues, for example the sex selection of embryos way to improve cognitive performance, this bias might result
(Banks et al., 2006) and life extension technologies (Partridge in the preference to not use PCE. This tendency, to use the

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Schelle et al. Attitudes toward pharmacological cognitive enhancement

status quo as a reference point, might explain why people pre- Banks, S., Scully, J. L., and Shakespeare, T. (2006). Ordinary ethics: lay peo-
fer interventions when they are seen as treatments as opposed to ple’s deliberations on social sex selection. New Genet. Soc. 25, 289–303. doi:
10.1080/14636770601032890
enhancements (Bostrom and Ord, 2006). It is also possible, how-
Bavarian, N., Flay, B. R., Ketcham, P. L., and Smit, E. (2013). Illicit use of pre-
ever, that users adopt a more positive view toward PCE in order scription stimulants in a college student sample: a theory-guided analysis. Drug
to reduce their cognitive dissonance, the discomfort experienced Alcohol Depend. 132, 665–673. doi: 10.1016/[Link].2013.04.024
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when one’s actions don’t reflect one’s beliefs (Festinger, 1957).
This would reflect a situation in which users adapt their attitudes dents’ attitudes towards the acceptability and regulation of pharmaceuticals to
improve academic performance. Neuroethics 6, 197–205. doi: 10.1007/s12152-
toward their PCE use, that is, their behavior. Future research is
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people’s attitudes toward PCE and the causal direction explaining memory in healthy individuals: an empirical study of attitudes among general
the attitudes currently prevalent. Further, future research might practitioners and the general population. Scand. J. Public Health. 36, 532–537.
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hold for other concerns, such as coercion and authenticity for (2013). The use and misuse of prescription stimulants as “cognitive enhancers”
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The epidemiology and cognitive neuroscience of prescription stimulant use by Copyright © 2014 Schelle, Faulmüller, Caviola and Hewstone. This is an open-
normal healthy individuals. Psychol. Bull. 137, 717–741. doi: 10.1037/a0023825 access article distributed under the terms of the Creative Commons Attribution License
∗ Sweeney, S. (2010). The use of prescription drugs for academic performance (CC BY). The use, distribution or reproduction in other forums is permitted, provided
enhancement in college aged students. Social Work Theses Paper 48. the original author(s) or licensor are credited and that the original publication in this
Teter, C. J., McCabe, S. E., Cranford, J. A., Boyd, C. J., and Guthrie, S. K. journal is cited, in accordance with accepted academic practice. No use, distribution or
(2005). Prevalence and motives for illicit use of prescription stimulants in reproduction is permitted which does not comply with these terms.

∗ References marked with an asterisk indicate studies of the public’s opinion

on PCE; their results are discussed in this review.

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