Evolution and the Veil of Ignorance

I’d like to begin by explaining three concepts. The first concept is reciprocal altruism. It is often summed up as “I’ll scratch your back, you scratch mine”, but this is an oversimplification. There is no conscious expectation of reciprocation involved. Unconscious bacteria exhibit reciprocal altruism by producing substances, collectively referred to as biofilms, that protect not only themselves but also the bacteria around them, with the “expectation” that in return for this expenditure of energy, the other bacteria in the biofilm will also expend energy producing these substances. Similarly, the one conscious species whose thought processes we can reliably analyze - humans - do not generally keep tally sheets of how much they have done for someone and how much they expect in return. While we will forsake a friend who abuses our generosity, the vast majority of the favors we do are not done with any conscious expectation of reward. Nor is our altruism limited to friends who are capable of helping us in return; we also give money to beggars we will never see again, and even donate to organizations that help faceless, nameless people on other continents who will never know that we helped them, let alone be able to repay us.

The second concept I’d like to discuss is natural selection. You probably already have a working knowledge of this, so I would simply like to address a common misconception: natural selection operates at the level of genes, not individuals or species. It is often said, even by scientists who should know better, that an organism performs a particular behavior “for the good of the species”. This is not the case. Species are not selected for, genes are. A possible rebuttal to this “for the good of the species” talk is that individuals only act for the good of the species when doing so benefits themselves, as in reciprocal altruism. But again, this is not quite true. Individuals are not selected for either, genes are. This is the reason for the second form of altruism, kin selection, in which an individual makes sacrifices for the benefit of its close relatives, or rather, for the benefit of the genes they share with these close relatives. The most extreme example of this is eusocial insects. The vast majority of ants, bees, and termites are infertile; they will never be able to pass on their genes. Instead, their lives are devoted to helping pass on the genes they share with their fertile relatives, particularly the queen(s) but also for the males who inseminate her.

The final concept is the veil of ignorance, a philosophical technique for determining the morality of a practice or policy. Pretend, for a moment, that you know absolutely nothing about yourself. You do not know your race, your gender, your religion, how wealthy or influential your parents were, your strengths and weaknesses, your opinions, anything. Knowing absolutely nothing about yourself, and therefore nothing about what your life will be like, would you support, for instance, slavery? Would you find this institution desirable, not knowing whether you yourself would be a slave or a master? Would you support a theocratic government, not knowing whether or not you would believe in the official religion? Would you support disability payments, not knowing whether you would be receiving them or paying them?

Now to tie it all together: natural selection operates from behind the veil of ignorance. It has no “knowledge” of the future. When a group of genes have been selected to be passed on, natural selection knows nothing about the creature they will create, whether it will be strong or weak, smart or stupid, fast or slow. In the case of humans, it has no knowledge of whether it will be rich or poor. All that natural selection can do is select for genes that program the host for a general series of behaviors that will result in those genes being passed on. And in humans, genes for altruism have been selected for. Obviously natural selection is not a conscious entity; I have referred to it as if it were such as a simplification. But nevertheless, it has come to a conclusion: a gene pool that contains genes for altruistic behavior is superior, in terms of how likely those genes are to be passed on, to a genome whose genes encourage selfish behavior.

It is often said that science does not make moral judgements. This is true, but as a utilitarian, I believe that it is only through the scientific study of a particular action’s consequences that we can arrive at an objective judgement about the morality of that action. As such, that we have been programmed by natural selection to help others has very real moral implications: genes that produce altruistic behavior are more likely to be passed on than genes for selfishness, and since organisms are nothing more than the sum of their genes, what is good for the survival of our genes is, with a fair number of exceptions, good for us. And since a group is nothing more than a collection of individuals, what is good for an individual is, again with exceptions, good for the group. Natural selection has decided, from behind the veil of ignorance, that a species that gives help to those who need it is better off than an identical species whose individuals look out only for themselves. We would do well to heed its lesson.

Study Drugs

I am writing this under the influence of Adderall. I have a prescription for 20 milligrams a day, a relatively small dose.

I do not have ADHD. Instead, I suffer from depression. Adderall is not approved to treat depression; it was prescribed to me “off-label”, that is, for uses other than those which the FDA has approved it for. Depression decreases motivation and concentration - two symptoms that it has in common with ADHD. After struggling for months to so much as fill out a volunteer application, I asked my psychiatrist for something to help me concentrate. “Like Adderall,” I suggested. I had never tried the drug before, but its reputation for increasing productivity is well known.

I left that day not with a prescription for Adderall, but for an antidepressant that was known to aid in concentration. I filled the prescription and added it to my daily regimen of psychiatric medications. 

My concentration increased, but I concentrated on the wrong things. Instead of becoming more productive, I found myself more likely to brood on the very things that caused my depression: past wrongs and my personal failings. I found myself becoming angry with very little provocation. My mood and self-esteem dropped. When I returned to my psychiatrist and told him why I had stopped taking the medication, he thought for a moment. “Okay, we can try the Adderall.”

At first, I noticed no effects. I still found it hard to motivate myself. My behavior did not change until one day, I decided to pick up a book. I used to be an avid reader, but lately I had found it difficult to read anything more than a few pages before feeling the urge to do something more immediately gratifying.

But on that day, I read for hours, captivated by the narrative. Finding myself able to enjoy reading again, I began trying other things I used to enjoy as well. I found all of them to be engaging and rewarding. I began to find joy in my writing again. Instead of looking at pictures of cute dogs on Reddit, I played with my own. My interests changed; no longer was the internet used to deliver an endless stream of funny pictures, instead, I began to devour articles about a variety of topics, including several about the use of “study drugs” like Adderall, motivating me to write this article about my own experience.

Adderall was not a miracle cure. In fact, a recent study on people without ADHD found that those who took Adderall scored no differently than those who took a placebo on tests that measured concentration, intelligence, or memory. The only significant difference between the two groups was in their response to a question they were asked at the end regarding how much they felt the drug had helped them in the tests. Those who had taken the real deal rated the drug’s impact on their performance as much higher than those who were given a placebo. This mirrors my experience perfectly. Adderall does not make you better at what you are doing, it simply makes you more engaged in the task.

It still takes effort to tear myself away from the computer to do research, or finally fill out that volunteer application I alluded to. But the stimulant’s effects have freed me from my dependence on immediate gratification. Aware of this, it came as no surprise when I learned that one of Adderall’s effects is an increase in the brain’s access to dopamine, a neurotransmitter that causes feelings of pleasure - and also greatly responsible for addiction.

There is a tendency, even among psychologists and psychiatrists, to shy away from classifying gambling problems and excessive use of pornography as addictions, terming them “compulsive behaviors” and reserving the word addiction for drug abuse. But there is at least one common thread tying these behaviors together: they all cause the release of dopamine. My addiction, or compulsive behavior, was the internet. An endless supply of funny videos and pictures, providing entertainment without requiring any sort of thought or mental exertion, and available at the click of of a mouse. But with Adderall providing me with the dopamine fix I normally got online, the barriers to engaging in productive work were significantly lowered. 

Knowing this, could Adderall be used to treat addiction, by freeing dopamine junkies who get their fix from drugs, sex, or gambling from their dependence on these substances and behaviors? I don’t know. A search of the scientific literature for any variation on “Adderall treatment addiction” returned only results about addiction to Adderall itself. Changing “Adderall” to “stimulant” and adding the word “gambling” did yield one study showing that the stimulant modafinil, another dopamine releasing agent, reduces the desire to gamble in high-impulsivity pathological gamblers - while increasing the same desire in pathological gamblers with low impulsivity.

It was rather predictable that a search for “Adderall” and “addiction” would yield mostly articles related to Adderall addiction. Concerns about stimulants and their use as “study drugs” are being raised from all corners. In February, the New York Times ran a front-page article about Richard Fee, who developed an addiction to the drug after first being exposed to it in college. After returning home, he obtained a diagnosis of ADHD - a ten-minute process of filling out an easily-falsified questionnaire. Armed with a diagnosis from a reputable physician, he found no shortage of psychiatrists willing to prescribe him increasingly large amounts of Adderall to feed his habit, even after warnings from his parents and clear evidence of psychiatric breakdown - which ultimately led him to commit suicide.

What happened to Richard Fee is tragic, and calls into question whether psychiatrists can be relied on to prescribe potentially dangerous drugs responsibly. But I fear that the story will turn popular opinion against the use of a drug that has great potential and, as the article notes, is non-addictive and not harmful when used properly. Richard would take “four or five” 50 milligram pills at a time, and purchased additional Adderall from a friend when his prescription ran out. 

I believe there are two lessons to be learned from Richard’s story. The first is obvious and uncontroversial. Psychiatrists - all doctors, actually - need to take a more active role in monitoring their patients for signs that they are abusing their prescriptions, and emphasize therapy over medication. Since I expect that I will receive no disagreement on this point, I will not belabor it.

My second lesson will be more controversial. While others may call for a crackdown on the prescription of stimulants, I would actually prefer to see these drugs be more freely available. Richard’s first exposure to the drug was in an environment where its abuse was seen as normal, where amounts of Adderall well above the normal dosage were taken both for recreation and to increase productivity. Perhaps if he had first acquired the drug from a competent physician who had educated him on the risks associated with it, his story might have ended differently?

Not likely, you say, pointing to the incompetence of the physicians who prescribed him the drug in his final months. And I agree: as I touched on above, the system needs to be overhauled, with doctors given far more education and training on the abuse of prescription drugs, to better provide these drugs responsibly. But the demand for Adderall is here, and it’s not going away. Seventy years of proscription, trillions of wasted dollars, and millions of people thrown in prison, yet marijuana, as well as more dangerous substances, are still available to anyone with $10 who knows what sort of person to look for while strolling through the poorer areas of town. More and more people at every level of society are recognizing that the War on Drugs has failed, in the same way and for the same reasons that Prohibition failed. The referenda that legalized marijuana in Washington and Colorado last November are only the beginning, and it is the duty of the medical establishment to embrace the role it has to play in promoting and ensuring responsible drug use. If an informed, consenting adult wishes to obtain a prescription for Adderall to increase their productivity, I say let them. Better that they are prescribed it by a doctor who can explain the risks and monitor their usage than buy unregulated, adulterated product from someone who stands to profit from seeing them become addicted.

Many people object to this use of Adderall and other stimulants by those who do not have the disorders they are used to treat, seeing it as analogous to the use of steroids in sports. But this is not a fair comparison. Firstly and most importantly, Adderall and other stimulants prescribed for ADHD do not have the same long-term health effects as steroids. Secondly, sports are contests of skill, and XKCD aside, it is entirely reasonable to view the use of steroids in a contest designed to measure natural ability as cheating. But while students and workers can certainly be competitive, the work they do in classrooms and offices is not a contest. If I use Adderall as it is prescribed to me, and while under its influence I write a paper that receives an A, I have not cheated. I have done the work and learned the material. My degree certifying that I have the skills and knowledge necessary to enter my chosen field does not become fraudulent because I learned those skills while under the influence of Adderall. 

One can argue that one of the skills college is intended to teach is how to be productive without the use of these drugs. But if the use of these drugs by people without ADHD is cheating, then how can it not also be cheating when they are used by people who do have ADHD? Shouldn’t they also learn how to be productive without the aid of drugs? I take four antidepressants and mood stabilizers in addition to Adderall, have I cheated at life by using drugs to become happy instead of learning to be happy without them? Perhaps. There is much to be said for seeking therapy instead of using drugs as a quick fix, and many of those raising the alarm about Adderall abuse have called for a greater emphasis on therapeutic treatments and less reliance on medication. But I posit that there is no logical distinction between someone with ADHD using Adderall to become more productive, and someone without ADHD using Adderall to become more productive. If one is cheating, both are cheating; if one is acceptable, then both are acceptable. 

It is said that there is a difference because the person with ADHD “needs” the medication, but then where do we draw the line between those who need it and those who don’t? Everything is a continuum when it comes to the brain; mental disorders like ADHD and depression are caused by a chemical imbalance in the way neurotransmitters are produced and processed - an imbalance which varies in magnitude. The discrete categories of mental illness found in the Diagnostic and Statistical Manual of Mental Disorders, psychiatry’s Bible, are a convenient legal fiction. In reality, there exist grey areas between what is considered normal and what is diagnosable as a mental illness. 

Imagine a world in which what we consider to be moderate ADHD was the norm. By current standards of who is and isn’t allowed prescription stimulants, in this world only the people who have what we would consider to be severe ADHD would receive medication, while those who would, in our world, be given treatment are instead expected to cope on their own - after all, their inattention, hyperactivity, and/or impulsiveness is “normal”. But since “normal” is merely an accident of statistics, why do we only consider it acceptable to use these drugs to bring people up to “normal”, instead of using them to help anyone who wants them to realize their full potential? Paul Erdős, one of the most famous and respected mathematicians to ever live, used amphetamines to aid in his work. After quitting for a month to win a bet with a concerned friend, he immediately resumed use of the drugs, saying “Before, when I looked at a blank piece of paper my mind was filled with ideas. Now all I see a blank piece of paper.” We can draw an arbitrary line to decide who receives stimulants and who does not, ignoring the potential these drugs hold, or we can realize the truth: that there is no line.

But what of the concern that the normalization of study drugs will lead to a scenario in which those who would otherwise avoid them will feel pressure to take them just to keep up? Against this, I can offer no real argument. I believe in the freedom of individuals to use drugs, but I have an equally strong belief in the right of individuals to be free from pressure to use drugs they do not want. The only point I can raise is that there is already one study drug whose use is completely legal and widely accepted: caffeine. Caffeine is even more potently addictive than Adderall - many who joke about being addicted generally do not realize that it really is an addiction - yet we have no qualms about letting people use caffeine to wake themselves up in the mornings, or even to continue using it heavily throughout the day to keep themselves alert and focused. We don’t even place an age limit on who can purchase or be given the drug. The effects of Adderall addiction are far more severe than those of caffeine addiction, true, but I am in no way advocating that Adderall become as freely available as caffeine; only that informed, consenting adults who wish to use Adderall be able to acquire it from doctors who can then monitor their usage.