 We're joined by Dr. Thomas Sanderovitz, who's the Director General of the Danish Medicines Agency. He's also the European head of the EMA. I'd like to start with you, Nita. Can you kick off our discussion? Every panelist will have five minutes. We'd like to encourage as much audience participation as possible, so please just, even if you're behind me, just put your hand up and we'll get a microphone to you to ask some questions. Nita, safe to say that you're pro-smart drugs. Yeah, I think I'm pro people having the choice to take smart drugs, which I think it's different than pro-smart drugs. I'm indifferent really on smart drugs versus other kinds of safe, potentially effective types of things that people would take. I think that smart drugs are not particularly different than most of the other things that we already do to improve our health. I think generally what we try to do as humans is to improve, whether it's to improve our health through the latest diet to exercise, which has been shown to probably be the most effective way to improve cognition and to improve health, or to ingest so-called smart drugs. I personally, under the prescription and advice of a physician, under all circumstances, have tried pretty much anything that I can try. So whether it's modafinil or any other kind of smart drug, I've tried them. I mean, pausing there, I should ask the audience, how many people here have actually, if you want to disclose, have taken a smart drug or know somebody who's taken a smart drug, shall we say? And a smart drug is could you classify a few of the ones, modafinil, riddle, and... Yeah, so I mean, I think new tropics is a kind of bigger class of what people think of smart drugs. But there are supplements that people think improve cognition and enhancements of different kinds of skills that you might have. It might be memory, it might be your concentration, your alertness, your ability to think quickly through a problem. But some of those drugs are modafinil, which is pro-vigil or new-vigil. The whole class of drugs that are prescribed for ADHD or ADD, which are things like Ritalin or Concerta or Vi-vans, these are some of the names and those are stimulant kinds of drugs. And then of course, there are non-prescription drugs that people take as well, Ginko-Belova, other kinds of herbal remedies that people believe will enhance cognition or memory or things like that. So how many people here have taken any of those kind of drugs and know somebody who's taken those drugs? Yep. Well, we shouldn't leave out caffeine, which I bet everybody here has taken, right, which is one of the ones that are the most ubiquitous. But not needing a prescription yet. Well, not needing a prescription, although there are much higher doses of caffeine that you can get in distilled form, right, rather than, I mean, not just neutropics, you can go in the US into a gas station and get no-dose or other kinds of distilled caffeine that are much higher doses of caffeine than you can get in a cup of coffee or in your espresso or latte that you might drink. Interesting. Yeah. Okay, so Andrew, can you explain a bit about your company, because you're doing a totally different sort of smart drug, I would say. Well, yes and no. So let's draw on this idea that the way you enhance your cognition is by your diet, your medicines, exercise, rest. So let's just then talk about how digital medicine can be part of how you really massively enhance your ability to make smart choices. So digital drug is a drug that contains a sensor inside it that's the size of a poppy seed that's made from ingredients in your regular diet. When you swallow a digital medicine, maybe a drug to treat your heart disease, it's gonna turn on and create a signal in your body. That signal can be detected by a little wearable device. We use a patch that's like a super fit bit, detects your medicines, but it measures your physiology, so things like your heart rate and your respiration and it tracks your activities of data life so we can track your rest, your rest architecture, and your activity and other things that show how well you are. It sends that information to your mobile phone and then you've got information about what you're doing with your medicines and how you're living your life and that can then be put into the cloud and if you choose, you can share that with your family or your care team and other people who are trying to help you. Why is that important? What we've shown in randomized clinical trials, which are the gold standard of course for how you measure the effect of a medical product, if you give us patients who've got high blood pressure, high blood sugar and high lipids, these are the global pandemics, they're everywhere. If you give us those patients who have all failed drug therapy, they've been on drug for at least six months and they have failed all end points and you put them on a digital version of the same drugs where they take them, they get feedback, they can share that feedback if they want to with people in their care team, then within 90 days, 98% of those patients are at their blood pressure goal, zero to 98% with major drops in their lipids and significant drops in their blood sugar. This is extraordinary, what's going on here? We're enhancing these patients' ability to make wise, healthy choices. How do we do that? The simplest human psychology possible, measurement, feedback and behavioral cues. This is how people learn good habits. By the way, if you start making good choices and you rest your body and you get exercise and you take your medicines, you'll keep making good, healthy choices. These are the ultimate smart drugs. And would you say taking a non prescription Ritalin dose to do better at school or increase your concentration is that your decision? I think the framing of this about things like Ritalin, Ritalin may or may not be a good idea. At the end of the day, food is a drug. For example, if you get a very little sleep, you are much more likely to have carbohydrate cravings and carbohydrates affect your serotonin system. Your brain is basically a giant chemical and electrical device and how you feed it and how you nurture it affects how you make decisions. So you can choose to feed and nurture your brain with chemistry and with chemical compounds or you can choose to feed and nurture your brain by making good decisions about rest and exercise. And so what I would tell you is, as Nita has pointed out, 100% of us are already doing this. We're making decisions about coffee, about donuts, about exercise, about how we rest. And these are fundamental to our brain health and our capacity to make smart decisions. And so what I'm gonna say to you is this is not the new norm, this is the norm. And what I would encourage people to do is to actually make good and wise decisions and actually to use, if you're in any way prescribed the medicine, a digital medicine, these are commercial products now in the US, thousands of people using them today, this absolutely within 10 years will be the norm. Every patient will have the chance to know when they use a medicine, whether it's real, whether it's fake, whether it's the right dose, whether it's the wrong dose, whether they take it at the right time or the wrong time, whether it works for them and how it affects their activities of daily life. And that is absolutely crucial to people making smart decisions and having good cognition. I mean, Daniel, does this speak to you? Do any of your students use these sort of drugs, you know? Might be difficult to tell, I guess. I don't think they would tell me if they do, but I'm just trying to think as an educational administrator in China what would be the relevant principle and I think the relevant principle would be what effect it has on the ideal of equality of opportunity in education. Because this ideal is widely held in China, it goes way back to the time of Confucius who famously said, which means that in education there are no social classes. He would take any student, regardless of their background, if they have the ability and the willingness to learn. And today in China, the one, while there's the National University Entrance Examination is called the Gaokou, and it's so important in terms of determining people's future in China. And it's based on this ideal of equality of opportunity in education and arguably it's the least corrupt institution in China, what's that? Let me put it, it's the most fair institution in China. And also it's central to be frank to the political legitimacy of the whole government because if that institution is questioned as being unfair, it would really undermine this whole ideal of meritocracy, which is central not just to education but to politics in China. And do you think students taking smart drugs might make that seem unfair? If those drugs are expensive and they're only taken by those from wealthy backgrounds, it would really send this message that if you don't have to study hard, if you just take those drugs, you can do better on the examinations and that would really undermine the legitimacy of the whole system. So I think if the drugs are expensive or available only to powerful minority and difficult to access, then I think, I do honestly think they should be rigorously banned and they should be tested for before this National Entrance Examination, just like we test athletes in the Olympics to, you know, cause steroids seem to give them an unfair advantage. But if the drugs can help poor people or marginalize people and give them a more equal opportunity, cause now the big problem is that if you're from a wealthy family, you can access better teachers and so on, you can better prepare for the entrance examinations. But if those drugs can help poor and marginalize people and give them more equal opportunity, then I can see there might be a case for that. But that would be difficult to police. I'm guessing you could stop the rich kids from having it. So if it's as accessible as coffee, coffee is cheap and widely accessible and doesn't have serious side effects taking moderate dosage, then fine. But until that day, I think they should be, to be frank, rigorously, you know, they almost banned to be frank in China. That's interesting, cause this is the issue that we're talking about as well, is how much do we know about the side effects of these drugs and are they actually smart drugs? Are these actually having an effect, Dr. Sender? I would like to call them dumb drugs. Probably not really called them drugs. Because as we've discussed prior to the session, I'm a regulator. So basically the whole regulatory framework looks as, does medicine help treating patients? And in here, we have to assume, well, some of those people taking them might be patients, but most of them would otherwise be healthy. So this is about enhancement of otherwise normal functions. I guess that's what we're talking about. Not in your case of what I think is really smart. And I do agree that that might very well be the future. So the question is, do we have a framework which allows us to make decisions? But I have to say we also regulate food which we ingest. And I think from coming from as a regulator, my job is to make sure that generally the public health doesn't suffer. We should make free choices and of course, but we should make sure that we don't want to sell cigarettes to underage, right? We want to make sure that public health doesn't suffer. So coming back to these so-called drugs, if there, and some of them are real drugs, they're intended to treat patients. I like to see some data showing that they actually work. And it's quite limited, at least by my standards, that they actually do anything good. It will require very large controlled trials to show that you're improving cognition and performance in randomized controlled trials. And therefore I'm not as supportive of these being widely used. If we have those data, of course, and if they are safe to use, I haven't seen big safety data starters yet. Some of them might not be problematic. Some of those that are used today, particularly those that are prescription drugs for ADHD, Ritalin, for instance, are absolutely not for public, general public use, in my opinion. Because what kind of effects would these drugs have if I started taking them and I don't have ADHD? Well, if you take a look at the package insert for Ritalin, for instance, there are all kinds of potential side effects, including changes in blood pressure and psychological changes. And youngsters taking those to school shouldn't take that without control. And now, of course, you're less likely to have severe heart disease when you're 20 than when you're 50 or 60. But then again, we can't just say they're only for youngsters. If you let it go, it's for everyone. So I do believe that there are some caveats around this. And that's a health discussion. It's also a philosophical and ethical discussion. Should we be able to choose freely? I'm personally very much against cigarettes being a legal thing. I think we should ban cigarettes. It's damaging to public health. We'd be able to choose that freely. So that's a philosophical discussion. I can see you needed smiling, because I know. I disagree, yes. Well, let me back up for a moment, which is just to clarify the difference of the kinds of drugs we're talking about first, which is there's two very different kinds of smart drugs that we're talking about. One is a drug that acts on your chemistry of your brain and your body to change something, whether it's to speed up the processing of information or to make you more alert. The second is to enable you to have much greater information about how a pill works, how your body works, how your physiology of your body works. And so it's being able to do something like quantify the body and the information from your body. And they may have very different implications for how we think about those kinds of smart drugs, which is smart in terms of making you smarter about your health and your body versus smart as in doing something to, rather than through information, more directly mediate your body. But, and so they may have different regulatory responses to it. I'm gonna focus on the latter, which is drugs like caffeine or Ritalin and Concerta and those types of drugs and say I wholeheartedly disagree that we should ban these drugs from individual use. And part of it is we're just not used to being able to regulate this class of stuff. This class of stuff which are not about treating illness, but about enhancing our bodies and ourselves. And so the traditional way that you look at drugs and devices, you say what's the safety and what's the efficacy? And for efficacy, it's a totally different ball game to say do you get a personal benefit out of it and how you value that information, right? The benefit that you get out of it versus the safety as opposed to does it actually treat the drug that it's supposed to treat? So if I have a placebo effect, if I believe that it enhances my cognition, if I believe that it makes me more weak and more likely to be alert, and the risk of it is I may get a headache or my blood pressure may go up and I don't have any pre-existing conditions that would put me at greater risk because of having a slightly higher blood pressure. I think I absolutely should have the right to choose that rather than a regulator deciding it's not effective enough. Because effective enough is a personal decision, not a regulator's decision in this context. But a personal decision based on what? Because some people- Based on my own personal values, right? Which is if my personal values are I would rather take the drug than go for a run this morning. Or I have terrible jet lag. Here I am in China on a 12 hour time difference and Madafino can help me reset my clock so that I am more awake and more alert. And I personally derive benefit out of that. Then I don't think that a regulator has the right calculus to be able to say it's not effective enough to make you alert. It's not effective enough to make you wide awake enough or cognitively inclined enough because that's a personal experience which is not well measured by our traditional regulatory approaches. If the drugs are expensive and they improve examination performance, you wouldn't worry about them? So that's not a question for me of banning regulation. That's a question of distribution of goods and services. And that's a question that we face with everything in society, right? I mean, who has access to tutors? Who has access to television and applications that improve? And these are real justice questions in society. So if it turns out that there's really good data that improves performance and we have a model of justice that distributes goods more widely that we think do that, then we should distribute it more widely and enable greater access to it, not ban access to the people who can afford it today. I think it's a separate question, but an important question, right? An important question about the just distribution of goods and services. Can I just build on some of the things that Nina said? I don't think these ideas are actually completely separate. And I'll give you an idea of this. So there are obviously drugs that have been approved that maybe don't enhance cognition. Okay, we did some experiments around the effects of using behavioral cues, measurement feedback, on how it would affect people and how they live. And so we gave people placebo pills and we called them motivation pills. And the idea was that if you set your, for example, diet exercise, your goals, your personal goals, right? And in the morning, when you were supposed to go for a run, if you felt like you might not, you could take a motivational pill, right? And you could take as many as you liked. And what we showed in that study was that people with motivation pills were more motivated and the more motivational pills you took, the more motivated you were. Which is a classic placebo effect. And by the way, placebo effects have been around for a very long time and they are actually increasing in society. And so, okay, this is a very, very important point because the chemistry of the brain is linked to much, much more than just the chemistry that's in the pill. I agree. So that's a really- But it's a neurofeedback approach, right? As opposed to, I was trying to distinguish, just to be clear, right? Which is neurofeedback, there's a lot of good data that neurofeedback actually improves cognition as well. The mechanism of the smart pill that you were talking about really is neurofeedback. Right, right. But if you use neurofeedback with the right chemicals, you're gonna sort of, you're enhancing the chemicals. So let's then go to this point about education and about do I worry about, should people worry about these kinds of things. For what it's worth, and obviously this isn't a debate about education, but educational systems around the globe in the 21st century are pretty horrendous, right? And so, the issues in education are miles beyond whether kids get access to caffeine or idylline. There are much more basic questions like can they get access to decent teachers? And so, I would really, really reframe that and say anything that we can do to perform the, or improve the performance of any child in any country and get ahead in an increasingly educationally intensive and knowledge-intensive world is a really, really good thing and focusing on not allowing that until everyone can get access would be a huge problem. It depends who uses them. If it's the rich student, so I already have all these advantages, then it's something to worry about. But if they're cheap and available to all and they help those who are from underprivileged backgrounds, then we should encourage them. A mental model that just talks about the rich like that's a static thing is a problem. The 20 most wealthy people in America all made their money in their own lifetime and most of them started out poor. So this notion that you can talk about the rich that like they're a static class is just a fundamental misnomer. And every young kid, wherever they are, any country in the world deserves a crack and I'm in favor of any way that they can get it. But does it say something about our society that we're trying to enhance our concentration in this manner, that we're increasingly trying to make it more competitive? Does that worry any of you? So just to answer that in just a nuance, I mean, regulators' job is not to ban anything. I just wanted to make that very clear. It's actually the opposite to make available stuff that helps. And I'm struggling with understanding how much they help. I do acknowledge that you feel that you're helped and that could very well be the placebo effect. And I also want to just for the sake of nuance saying there's a difference between caffeine and Ritalin. Right? We really need to understand the continuum of rather dangerous substances that are close to placebo which might very well help and stuff that potentially could be harmful. So at least if we are applying it to the masses, I think it should not be harmful. And I'm missing for part of those so-called smart drugs, I will refer to them as dumb drugs, they are harmful or at least I'm missing enough demonstration about the potential harm. I do realize that we can't apply the same framework. So that's just about getting the nuances right. Then back to the other question about the rich where that becomes philosophy which is out completely outside the realm of a simple regulator. Sure. So I mean on the point of banning, fair enough, right? I mean, there are alternatives, but it's, I don't think the case that everything that we do has to have some sort of therapeutic benefit. Take cosmetic surgery, right? Breast augmentation, rhinoplasty. Those are positive things for people to be doing. If people want to do them, go for it from my perspective. And they have significant risks associated with them. And they're anesthesia risks, they're surgery risks, there's all kinds of risks that are associated with them. Tattoos have risks to them. The health risks and the consequences. And yet we allow people to adorn their ears and adorn their bodies with tattoos and arts. What do you think is a free choice? Because things like breast augmentation, is that maybe something that society is putting on some women that they think they might do that. Right, so I know you want to go here. So let's go here for a moment, which is, which is the kind of race to the bottom, right? So people are really worried that when you have available drugs that the implication for society is that the only way that you can keep up is by taking the drugs, right? And in some ways, it's true. If you have a very effective thing in society for improving performance and improving cognition and improving your ability to stay awake and be productive, there is a pressure to use them. People now almost all use computers, right? People, the distribution of cell phones throughout society is quite large. The use of the internet to do research, the use of email for communication, for rapid response to communication, it has changed fundamentally society. And people have had to keep up, right? You can't now send snail mail to somebody. You have to actually send emails, which means that the rapidity of communications has risen. Is that a positive development? Well, I mean, it's true. Whether it is positive or not positive, it is true, which is society and humanity is always looking for ways to improve. And the question is, is a life in which we are able to be more alert, have longer and better memories, are able to be less anxious in certain situations, is that a better life? And those are deeply- But why use drugs where you could use meditation, you could practice qigong, you could use all kinds of things. And some of those are actually better. So neurofeedback is more effective in many instances than most of these drugs are. Using meditation has been more effective for calming than most of the different drugs that are out there. So these aren't mutually exclusive. They're all part of a continuum, all options that are available for enhancement. And not everybody will use them. And not everybody should use them. There are side effects for some people, they don't work for some people, they don't enjoy them or they don't wanna change themselves in those ways. I don't believe that there's gonna be an imposed requirements, but I do believe it should be part of the options that are available to people to choose. I mean, it's interesting the imposed requirement because I've read recently there's been some experiments between the Beijing to Shanghai Railway where train drivers are wearing these kind of caps. Yeah. So basically they're monitoring their concentration as they're driving. Right. Pro or anti this panel. Is this a good development? To monitor workers while they're... I worry about that a lot actually. I worry about something different. And it's actually two sides of the same coin, which is I think we have a right to cognitive liberty. Right. And that cognitive liberty is the right to self access, which you're really working on, which is terrific. It's the right to self determination. And it's the right to some freedom of thoughts and mental privacy. And what I worry the most about is when we're tracking what's happening in people's heads, particularly workers, truck drivers, people who don't have the option to opt out, that the better that information gets, the closer it gets to being able to decode things like visual imagery or thoughts, which we're still a long way away from, but the closer we get to that, the more problematic it becomes as people need to censor their thoughts and as we intervene. I don't worry about it as much. I mean, the main task of a train driver, so to speak, or conductor is safety. And if that helps improve safety, then that should be the main... But what happens if it goes down the track that they can enhance their performance at work by giving them a smart drug, measuring the impact on the brain? They can work longer hours? Yeah, I think personally, look, this is a real red herring from my perspective. If you just think about where we are from a transportation perspective, we have trains, we have cars, we now have self-driving cars. If you really want to get out there, you can go see videos of self-flying planes. In fact, you don't just need to see videos. What people should know is that most planes today are flown without pilots. The pilots sit there and the plane flies itself. If you want to use these kinds of technical advancements to make things safer, you don't need to monitor the pilot or the train driver. You need to use the technology in the train. And so that's not an interesting... But they're using it for truck drivers. They're using it for factory workers. Electricity company workers. Yeah, but you make a point about cognitive liberty. But I would just say, look, not only is it just about cognitive liberty, it's not a good strategy if you want to promote safety in a workplace. So get rid of the workers and get the self-driving technology. Well, so I just think that there are many, many other much more effective ways to effectively use machines to augment human effectiveness rather than using technology to check on whether human beings are being effective. I think that's actually the wrong pathway. It's just intellectually the wrong... It's a technical question, whatever works, right? I mean, we agree that there's a trade-off sometimes between liberty and safety. And if you can have more safety without fundamentally undermining liberty, then, and if that's the most effective way of doing it, then I don't see a problem. So I'm just gonna be a little bit provocative. So in reality, to have that liberty, to make choices, why should we regulate anything at all? Yeah, yeah. Right, so that's really the question. So let's just all take drugs and whether they kill us or not, whether they work or not, we really couldn't care. I'm all for improving safety profiles, but yeah, if you want to go there... So we see that's a continuum basically. So who cares whether you get deficient birth deficiencies when you take medicine? When you're pregnant, who cares about that? We go right back to the Calidamide scandal. So basically that's not a problem. As long as we feel good, we can just take it. No, so I'm tongue-in-cheek, right? And you're right, you're being provocative. I'm not saying that we should liberalize everything, although you could probably push me to that point. It's for some things, but I want safety and efficacy data in the same way that I want the quantified self and the ability to improve health by empowering individuals and empowering consumers. I think that regulators empower consumers by forcing information, right? And I think the forcing of information is incredibly valid. And there are certain things, like you point out the Calidamide, we're talking about implications not just for the self, right, but for future generations. And should I be able to take drugs that would affect an unborn child that would lead to birth defects forever? If I don't have that information, then I can't make that choice. I can't make an educated choice. And society pays a great deal. Your point is an interesting one, because you've implicitly said it, but we should make it more explicit. It's the difference between some of the Western and Eastern bioethical approaches, right? Which is the emphasis on the individual versus the emphasis on the community. And you would lead to pretty different outcomes and intuitions about what would happen. So at the end of the day, it does depend on ones we can call it, as you said, justice, but also philosophy of the good life. And I think we can call it the Confucian view that the good life lies in having harmonious social relations. I mean, that would lead to somewhat different views compared to the more libertarian view that might be more prominent in the US. I'm just gonna open it up to you some questions. Can I grab that microphone? Yeah, go ahead. Could you just introduce yourself and where you're from? Yeah. So hi. Can you hear me? Is it working? Can you hear me? Yeah. I'm from the University of Romania. I am from the University of Sussex in the UK. So my question is somehow these drugs and smart drugs or smart substances, whatever we take, imply that the person is intelligent enough to know what they're doing. And this intelligence is not pervasive. So what can we do to educate people about the process? If you don't wanna regulate, at least we need to educate people about what is good, what is safe use, what is not safe use. Even for caffeine, we have some understanding or notion of what is safe limits. Who should take them? Who should not take them as well? How do we manage that process? Thank you. So I'll give it a shot at least. Well, that first assumes that those who manufacture these and produce these are willing to accept the system by which they generate these kind of data, that we have a framework. I do agree that the current framework for assessing this is geared towards patients and not towards otherwise healthy trying to enhance. So there might be a value in looking into moderating or developing a framework, a regulatory framework. I'm all for that we take these things. I'm not again, I'm not banning anything, but I want data. I want to know in fact that they do enhance intelligence. I have not seen a lot of trials basically telling us they enhance them. Can I challenge you on that? I really wanna challenge you on that. On this debate about regulation, there is a very clear public health argument that says safety is very important. But the notion that regulators demand to know whether things are efficacious in my view is somewhat spurious because many, many drugs have very, very different effects in many different people. Today, efficacy means you have a 5% signal across a population that a drug works. I speculate if you had six fingers, it would be a 6% signal. It's a very shaky in my view way in which to get access for populations to products and services that they may wish to buy. If they're safe, I don't see why you need to have any data about whether people in the Trump thing they want. So just to interrupt, Nikola here was shaking her head when you guys were talking. I just wanna go. No, I just had a couple of comments. I'm a neuroscience professor. The first is I wanted you, no one's really defined what you mean by smart drug. And I think most of the evidence is it's perhaps increasing your focus on a particular task. We're not really talking about increasing intelligence. That's what you have. The second comment is, it's all very well as an adult. You might decide I want to take this. This is my decision. But we're talking probably about children here when the brain is still developing. So I think that's a very different thing if you're making a long-term change to their brain development. I wholeheartedly agree. And I think it's, when I say that I think we should make it available to people, I really mean adults. I think there are- So we're regulating the age at least. Yeah. I'm happy to hear that, we can go that far. And for some things, everything we do with children changes their brain. Neurofeedback changes their brain. There's lots of things that people are doing at home reading to their children that changes their brain in good ways and in bad ways. And so we can't regulate everything we do with children. Reading to children doesn't raise their blood pressure or lead to any other kind of- Right, so this is why safety is so important. But I wholeheartedly agree that when we're talking about this class, I mean, why do you need efficacy data? Hang on for a second, just for sure. Just for sure. So of course, efficacy in the old-fashioned blockbuster ways is being challenged by precision medicine. Yes. A big topic yet. So we don't disagree. However, it is nonsense just to talk about safety. No drug is safe, first of all. It's all about the balance of benefit versus risk. And you can't talk about safety without really seeing the relationship to the benefit. You know, are you willing to take a chemotherapy medicine for your headache? No, you're not. You're willing to take it if you have cancer. So of course, it's in the context. In this context, and I wholeheartedly agree, is it beneficial to give adolescents or kids something that can enhance their brain? And why do we regulate for kids? And how do we know that there are no long-term harm for stronger enhancers? So that's my point. How you measure efficacy, and whether that's done good enough, of course, that's a separate discussion for another session we can take later on. But that's also improving in the regulatory field by the introduction of precision medicine. I want to take a couple more questions. So Gemma, use my mic. Hi, yes. I'm based in the UK, where we have the NHS, the wonderful NHS. And so obviously, a lot of the prescription drugs are free or very low-cost. And just kind of this discussion, you're talking about placebo effects. It kind of made me think a little bit about homeopathy. And there's huge campaigns in the UK to ban the NHS prescribing homeopathy because there's no evidence for it. So how do you make a decision as to whether you should publicly fund drugs that we don't necessarily have data on, even if they might have public good, and therefore make it fair? Thank you. That's a wonderful and such a hard question. Yeah, no, I mean, it's a great question, which is public funding decisions, when you're talking about scarce resources, here's where you probably do want some efficacy data, because safety data, without any data that says what it does, or if it does what it does, doesn't justify funding. And then, of course, you come to the problem of, OK, so now you have something that there's popular belief improves cognition. And to your point, right now, it doesn't increase intelligence, although there's some question with midaphanel as to whether or not it does improve performance IQ. And so there's a widespread popular belief that it improves cognition, but there's no data that it does. Does it justify public funding of it? Probably not, right? Because in a choice of scarce resources, you're going to focus on health before you're going to focus on enhancement in the same way that we don't fund other elective kinds of cosmetic surgeries. We're not going to fund other kinds of elective choices to enhance yourself, either, unless there is a therapeutic benefit to it, which makes the unfairness problem. It's not a public health question, though, then. It's a different question about not whether or not the public health system supports it, because if it's not about health, if enhancement is about an elective choice, there are other government functions that aren't just health-based functions for distributions of goods and resources, just like education. And again, you'd want efficacy data. You'd want efficacy data to say, we know education works. Do drugs work? So go on, Dave. In a Chinese context, I'm just a member, this national examination at the university is so important in terms of shaping people's future career. And there you can get, it seems to me, it wouldn't be hard to get efficacy data. If taking the drug improves the concentration, it helps examination performance versus those who don't, you can easily measure that. And once with that data, one could take a decision, depending on one's view of justice. I'm just going to bring in a few more questions. So Hannah, you had a question? I'm Hannah from New Zealand. My question, kind of coming back to, so if smart drugs are as common as coffee, there's been a lot of talk at this conference about how the skills that we need for the future are creativity, innovation, like deep critical thinking. And it appears to me that a lot of these drugs just enhance you to do things faster and quicker, but not necessarily in that deep critical thinking skills that we need. So I'm just curious about what, if you think smart drugs are effective, where is this going? Is there something that can enhance that side of things? I think that's a really, really interesting point myself. One of the things that I believe is happening and certainly happened in the United States is that fast intelligence is greatly overvalued and slow intelligence is greatly undervalued. And what I mean by that is that things that require really deep thought, knowledge and flow take much more time than answering multi-year, multiple choice questions and tests. And so I think that's a problem in many aspects, for example, the American educational system, where people who are very, very, very capable, but who maybe have slow intelligence and don't do well in fast test environments are grossly discriminated against. And I think that's a problem in many modern systems. Anecdotally, it is believed, at least, about Modafanel, that it isn't just about increasing the rate of firing in the prefrontal cortex, how quickly you think. Anecdotally, there are claims that it tends to enable people to have greater conceptual thinking, to be able to integrate multiple streams of thought that enable them to be more creative. There's no good data on this at all, to be absolutely clear. That's why I say it's anecdotal. There's no good data on this. We were discussing that. I had a colleague at the BBC made a film about this and he found that he really suffered taking Modafanel, but you were saying pre-opsy took too high of a dose. He might have, right? But I mean, so it's completely anecdotal, but they've done polls on this and that's the claim. And I say that only to say it's not clear what these drugs are doing. It's not always the case that it's just meant to target wakefulness and that it comes at the cost of creativity and other forms of intelligence. And when people talk about the broad concepts of enhancement, they include things like taking pro-panelol, which is a beta blocker that a lot of actors take before going on stage, which decreases their anxiety and enables them to perform better. And so I think if we think about enhancements much more broadly, enhancing social functions and enhancing personal functions, that's a much broader class of types of things that people are doing. I just want to add that it is just a problem for me that anecdotes, as you point out here, sometimes communicated by YouTube videos gets a whole generation of youngsters to do something totally undocumented. It really pisses me off. And it's really, and we see it all over the case, we see it with cannabis now. We can start that discussion. It's anecdotal and there's very little evidence and it's the same with these so-called dumb drugs or smart drugs. It's anecdotal. I think my question is quite timely then. I would like to draw an analogy here to the industry of vitamins. So now, don't get me wrong. Nutrition is incredibly complicated. There is evidence that people do not have enough vitamins and definitely supplements have a place. I'm not saying anything that this is not medically true. However, we now have a whole snake oil industry that is making millions. This is completely unscientific. I have no idea how much millions they're making, but they are making millions of the ignorance of the public. And you can talk about how effective they are. You're relying on the consumer to dig deep into boring data sets to understand how the effectiveness of this, and they are up against really expensive, flashy advertising campaigns run by companies. So I don't, I think we have the responsibility to give people good quality and easily digestible information to help them make the correct decision. It's not enough to just let people, to throw them in there and force them to make their own decisions. Yeah, so there's a planted axiom here, which is that everyone in the world is dumb, and I have a very different planted axiom, which is everyone in the world is smart. There's a reason why the value of brands is collapsing. It's because if you talk about needing to give people information, we have this incredible thing called the mobile internet, and knowledge asymmetries are collapsing, which is why people don't use accountants. They file their own taxes. That's why they don't use lawyers to go to legal zoom. And so it's one of the most brilliant aspects of modern life. And so this idea that YouTube videos enrage you, well, they might, but actually consumers are smart. They see through them. They figure it out. It's the best thing. If you go back- So if they're so smart, why is vaccination rate dropping across Europe? That's not pretty smart. I would just challenge you on this and say, look, this argument about more information is bad goes back to pamphleteering and the invention of the printing press, when elites who feel like they can be in protected positions because they have privileged knowledge and say, it's terrible when other people get to find out what we already knew. So I'm highly, highly in favor of distributed knowledge architectures and allowing individual consumers to make informed decisions that work for them as individuals, rather than societies in which you control information and to say, we are, as special clever people, going to make decisions for you because we know better. I wholeheartedly agree. It's a polemical point. Yeah. So I'm more of a political scientist and I looked at the data of whether voters are well-informed and it's so infinitely depressing. I'd be so much surprised that consumers are more informed. Totally agree. But the fact that they're not that well-informed is all the more reason to empower them with information so that they can make choices. When you said we shouldn't force consumers to make a choice, I want to challenge you to say, we shouldn't force consumers to dig deep into very complex data sets. But why not? I mean, who is more invested in your health than yourself? Who is more invested in figuring out for you what's right than yourself? As a scientist, I know how difficult analysis is, right? And I'm just, what I'm saying is that it's very difficult. I'm not saying that people are dumb. That's exactly the opposite. I'm saying they are time challenged. And if they have to make complex decisions, every time they go to the supermarket to choose a vitamin or to choose a smart drug or to make a decision about their child or themselves to get a job, to pass an exam, you're adding to that cognitive load in a way that isn't necessarily healthy for anyone. Yeah, and Potion has a comment. It's not just about, I'm not claiming that consumers are dumb. It's not about, at all, I never said that. And I think consumers are pretty smart. But however, I would like to, if I am ever having brain surgery, I prefer an educated brain surgeon to do so, not just my neighbor who's not, right? And if you are going to make choices about complicated medicine and you have to make choices about that, you prefer to have someone to guide you and help you. And if there are damages to your problems for public health, you need regulations to do so. This is not about, it's not either or. It's not polar-wise. I'm not trying to put you out of a job. I agree. But you know, these are complex choices. These are complex decisions. We have a question, Potion. Hi, I'm Potion Lo. I'm with a young scientist. I'm a math professor at Carnegie Mellon University. I'm actually also the national coach of the United States International Math Olympiad Team, speaking of Olympic competitions in intellectual pursuits. I was also one of the people who raised my hand saying that I know of people who have taken such drugs. And when we talk about multiple-choice exams, these are extraordinarily complicated exams requiring immense creativity. There is a correlation of, well, there are some gold medals that have gone along here too. But the thing I want to talk about is in support of the regulation. I want to challenge this notion of good. Because actually, I'll relate a conversation I had over lunch with some extremely distinguished mathematics researchers. They were not kids. They were adults. They were ERC grant recipients. They are very distinguished intellectuals about this hypothetical question. Suppose there was a smart drug that would take 10 years off your life, but you would then have successfully published one of the leading results and become famous. Would you take it? Now, among this group of esteemed individuals, there was not a consensus in the sense that some said, yes, I would take 10 years off my life to do this. The notion of good is very complicated because now I'm going to take the next extreme and say, why do they want to do this? It's for the great pleasure. Now, the heroin addict. They don't mind apparently taking 50 years off their life for a feeling of pleasure that is probably more intense than winning a Nobel Prize. Would you support that as well? Need it. Thank you for that. So heroin is an easier case for me. And I will say no. I would not support enabling free and easy access to drugs like heroin. But I think that the conundrum is one that we talk about in philosophy a lot, which is this idea of personal choice, right? I mean, people have done it in the extreme to say, if you could have one day of absolute exquisite pleasure, a kind of utopia that you never could have imagined otherwise, and you would die at the end of that day, would you take that drug? And some people say yes. And in a very individualized society, a libertarian society rather than a more communitarian society, should you enable the person to make that choice? The answer, if you were following a very strict libertarian approach, would be yes. A communitarian approach would probably say no to that, because the effect on the community and society is too great. It's not worth it. Where I live personally is somewhere in between, which is it's a balance between individual and the society. And you have to find the right balance. And there are certain drugs that are so destructive to society like heroin that absolutely we need to regulate them. I believe we need regulators. And I believe we need regulators. You're welcome. I believe we need regulators in order to sort of information forcing function. And the question really in this enhancement debate is what information is relevant? And we agree that it may need to be a new paradigm, a new framework to be able to determine what's the relevant information, because traditional efficacy in this example and in other examples is very different when it's personal values. And it's harder to measure, because how do you quantify improved performance, a sense of well-being, a sense of joy, a sense of happiness. And that context, as we've clearly heard, it depends on the society you're living in. So you would need different paradigms from different regions, I would assume. That's right, yeah. And just on this issue, it wouldn't just be in a more kind of communitarian or Confucian society, it wouldn't just be the individual who decides to sacrifice their life for increased pleasure or even writing a great paper. You'd also have to ask the parents what they think if the elderly mother isn't in favor of my dying for one day of instant pleasure, then maybe I shouldn't have that right. Right, great. Are there any further questions? I think we're running close to the end of the session. Oh, sorry, sorry, go on. Asmar Raji, I'm from Saudi Arabia. I'm gonna go back to the regulation part. The more regulation, the more there is a black market. I know my country, school is very competitive, and on the test time where the exams, there is, it's famous that keptagonies or other pills of some street names are more solved at these times, and then many kids go to hospitals for these pills. So if there was a regulation to these pills, people would probably take the good ones, not the ones that's sold on the street, which are poison or something else. Yeah, so, I mean, that's another reason that I believe in regulation, because regulation is not about safety, and obviously we talk about that, it's also about the quality of what's inside the stuff you're actually taking. And I'm a deep believer in, and I've seen the results, if you don't, that you know what's inside. So if you have a regulatory paradigm, by which you say these here are okay to take, and actually we demand that the manufacturers put in it what they claim they have in it, we're in a better position. But this will require more than the 10 minutes or five minutes we have left to develop such a new paradigm of regulation. I still believe in regulation, but I think it's a continuum, it's of course, I wouldn't want to regulate coffee by all means, but I do want to make sure that you don't give so-called smart drugs, and just the fact that they're called smart drugs shows that we need more regulation, at least more debate about it, because some of them may be good, and we don't know what good means, because that's contextually decided, and some of them may be harmful, and that's why I don't think they're smart yet, at least. Okay, so we've got about 10 minutes left. Oh, go ahead, Jemma. That's right, yep. I'm actually just building on the heroin thing. I was just thinking a little bit about, we're talking about, you talked about individualism versus community, right? And so the community effects of heroin are really bad, and it's not just a case of someone dies, they have children, and blah, blah, blah. There's also the supply chain effect, right? So there's a lot of bad that happens in the quest of getting heroin from X to Y. What about these smart drugs? What does the supply chain look like for Ritalin, for caffeine? There's lots of issues in the supply chain of caffeine. When we think about self-driving cars, we're thinking about cobalt, and the issues with the supply chain of cobalt, and actually is it really a good thing to keep having electronics? What's the deal with smart drugs? If you have higher demand, what happens to supply chain? Well, we already have a black market for smart drugs, right? I mean, the challenge, and I took your question to be slightly different, which was, it's incredibly important that we know what's in the drugs, right? So that's one value that regulators provide, they provide money, but one value that they provide, right, is to do quality control and quality testing. But the risk of regulation is that it can drive a black market as well. And you see in college campuses around the US that there's a black market for Ritalin and for these kinds of drugs, and you have students who have access to physicians who may be willing to prescribe it, even though they may not have the indication because they have wealthier families who are able to afford them going and getting the drugs, and then you have this black market that develops on college campuses and so you have this significant distribution problem as well. And then a great question of what is the quality? Are they getting the right drugs? What are the effects of it? Nobody's monitoring them. Many of, especially the class of drugs for ADHD do have significant effects because they're stimulants and the stimulants can be problematic and they need to be appropriately regulated for the correct dosage and for monitoring of the different health effects that they have on the body. And so finding the right balance, right, which is understanding that anytime something may have efficacy or perceived efficacy, over-regulation can lead to a black market which can create more insidious effects and the supply chain looks quite dangerous in those instances. You have people pulverizing these drugs and mixing them with other things and who knows what the safety of the things are that they're mixing them in with. So black markets are far more dangerous than open markets and how you find the right balance and regulation so that you don't create a black market is a really wonderful question as well. Can I just make a couple... So we're spending a lot of time now. We've got into this very deep conversation about using drugs for cognitive enhancement. And what I would say is, okay, diet, exercise, rest, medicine, they're all drugs that affect your cognitive... Are they drugs, though? Well, to the extent that they have effects on your brain and its performance, then in my view, they have very similar effects. Now, okay, maybe technically they're not drugs because they're not going to get regulated the way a drug would be regulated. But this notion that, for example, and I think this is very problematic, that you can actually turn these things into highly regulated products that are then highly valued and where industries then start to pump and promote them is very problematic to me when there are much simpler ways in which we could think about creating much broader, very positive population effects around how people enhance their ability to live well in modern life. And surely that's the answer. Well, they're not mutually exclusive. Of course, you wanna do that, but then if there are drugs that have either dangerous or unfair effects, then we might still think about regulating them. Well, or if they have positive effects, I mean, it's not as if I'm suggesting that you don't exercise or that you don't do neurofeedback or meditation or other improve your diet, which are all more effective right now than any drug that's out there for cognitive enhancement. But if you also get on a plane to China and have a 12-hour time difference and going for a run first thing in the morning and it doesn't keep you awake for the next 12 hours and a dose of the Daphnil does, No. Okay. No, but a dose of the Daphnil does, then I mean, why isn't that part of your overall strategy for? Is that not just a shortcut that feels like, I don't know if it's, it feels like maybe that brings less meaning if that's such a thing. Well, I mean, it helps me show up. So that's meaningful. So I think all of these things are fine. I just don't think that there are so many people, perhaps like you, who get on a plane for 12 hours, come to China and appear bright as a button on a stage with the kind of energy and VIN that you're displaying. And so, look, that's great. And I wanna know actually what you- It's the Daphnil. No, I actually don't have any with you. I wanna know what it's about. I wish I had some with me on this trip, but no, yeah. But just more broadly, when one thinks about it, because you asked about this as being a new norm and we talked about, for example, kids on college campuses, I have five children, two have graduated, two are in college and one's in high school. And so, these are things I look at a lot, because I look at- Are they taking these drugs, you know? Well, you're aware of it. Let's put it to you this way. None of my children have prescriptions for these kinds of products, but all of these young people have, in my view, pretty interesting lifestyles. When it comes to, for example, they get not nearly enough sleep when they're in college. They consume vastly too much alcohol when they're in college. They tend to exercise, that they have all kinds of other fun activities. And so, I think there's a whole conversation that has to be had about the culture, for example, of college life and campuses that should go well beyond this idea of are you taking no-dos or Madaffinil. I think that's actually that. Just framing the conversation that way is problematic. I agree. I think it's a holistic set of options and understanding where it fits within that holistic set of options is important and valuable. And especially, people understanding that today, most of those drugs are not as effective as any of the other interventions that you might use to improve your cognition, your memory, your wakefulness, et cetera. That's why I call them dumb drugs. Yeah. We have a question, Sangha. You have a question. As a college professor in neuroscience, in Korea, which is, and I just moved to Korea about a year ago and realized how stressed out and kind of performance-driven all the students are there. I think it's really actually highly dangerous for people like us in a forum like this to be calling things like cognitive enhancing drugs or smart drugs. Even that terminology really worries me because if it gets out there and students pick up on these things, given the unknown long-term effects and societal effects, and I could already imagine Korean moms going crazy to find out more about these smart drugs for the college entrance exams. I think we have to be much more careful, even in the way we talk about it at this forum. We have a question back there. And one more over here, yeah. I've got a microphone here. We've got about three minutes left, so go ahead. My name is Kristin. I'm also a scientist. You guys are surrounded by scientists in here, which is a high-pressure situation. I wanted to build on what you were saying and point out that some of what people are seeking with cognitive enhancement is actually recovery from or escape from mental illness. And a lot of what's happening in pharmaceuticals for mental illness is that drugs are not working, but people are solving their own problems with things like anesthetal cysteine and enositol and GABA. So when we're looking to enhance people who are healthy and thinking negatively about it, we also have to keep in mind that the same jump may be what people are using to get out of a really crippling and paralyzing situation. That's a good point. So I think that's about all the time that we have left. Just wanted to take a quick show of hands after hearing that discussion. Try and be honest and say, would you now think about taking a smart drug in your life to enhance? A lot of shaking heads, one, two. Yeah, okay. So that's great. So thanks everybody for coming to the session. It was an absolute pleasure to have the discussion and I hope you enjoyed it anyway. Thank you.