Bad Moves: How Decision Making goes Wrong, and the Ethics of Smart Drugs

Barbara J. Sahakian and Jamie Nicole Labuzetta. Oxford University Press: 2013. 192 pp. £14.99

9780199668472

Decisions can be as trivial as which coffee to order or which wine to buy, or as consequential as who to marry or which job to accept. Yet even the most profound choices are rarely made on strictly logical grounds. We don't weigh up pros and cons and dispassionately pick the best course of action. Our emotions and attitude to risk, how a situation is framed and the time available all influence our final choices.

In Bad Moves, Barbara J. Sahakian and Jamie Nicole Labuzetta lay out the neuroscience of how people make decisions and the ethical quandaries that accompany the use of drugs to enhance cognition. Their slim book is admirable in reviewing these important topics, but it does little to explore the wider view of how emotions can be regulated by drugs.

Credit: ILUSTRATION BY ALEX ROBBINS

Sahakian, well known for her research on the neuropsychology of affective and cognitive systems, and neurologist Labuzetta use people with dementia, depression, mania and phobias, who tend to make poor decisions, as exaggerated examples of how we can all err. Abnormal functioning of the frontal lobes and deep limbic structures in the brains of people with these disorders disrupts their emotional control and thus decision-making ability.

After discussing decision-making processes in the brain, Sahakian and Labuzetta explore cognitive enhancers. They focus on cholinesterase inhibitors and stimulant medications that can improve memory, sharpen attention and boost concentration. Such 'smart drugs' raise an ethical question: if drugs developed to treat people with cognitive disorders can also make people with healthy brains smarter, should we use them?

There is no simple answer. Smart drugs can make us more efficient and productive, which may be a good thing for society. But there are many reasons to be cautious. The long-term safety of ingesting these drugs is not fully known, although stimulants can be addictive. Easy rewards from these medications undermine the value of hard work and threaten our ideas of authenticity. And the availability of such drugs could compromise our liberties.

We could feel compelled to use drugs of this kind if all those around us are taking them and appear more productive. We might even insist that some people, such as commercial pilots and medical residents, take cognitive enhancers. And variations in access to smart drugs could raise concerns of fairness and justice, particularly if the advantages they confer are available disproportionately to the rich.

Although the book's themes are timely, the link between them is not transparent. After the authors make the convincing case that emotional dysregulation can cause us to choose badly, I expected a discussion about our ability to regulate emotions chemically. Surprisingly, the authors make no mention of antidepressants, anxiolytics and mood stabilizers, and the ethics of their use in healthy people. As a result, Sahakian and Labuzetta's diagnosis of the emotional source of bad decisions is disconnected from potential interventions.

Nonetheless, Bad Moves offers a good introduction to issues that affect us all. As the authors astutely point out, academics are not the final arbiters of the ethics of cognitive enhancement — these are societal concerns. With this accessible primer, full of medical anecdotes and clear explanations, Sahakian and Labuzetta prepare the public for an informed discussion about the role of drugs in our society.