Examples of relevant neuropharmacological agents used for enhancement include selective serotonin reuptake inhibitors (SSRI) that can make nondepressed persons feel even better with side effects that can be mitigated by yet other drugs, methylphenidate and amphetamines that can increase attention focus and sustenance in persons without attention-deficit hyperactive disorder (ADHD), ampakines that can further improve normal memory, modafinil that can increase wakefulness in persons without narcolepsy, and sildenafil that improves sexual performance in some normal males (Farah 2002).

Issues of ethics abound in all these uses. Chemically altering and then readjusting our internal environment has biological implications in the long run. Functional costs sometimes exist, as in the case of memory expanders that tend to reduce capacity for generalization in reasoning. On the other side, it may be paternalistic to disallow adults to choose for themselves. Also temporary enhancement may be required in unusual circumstances such as combat situations. What must be advocated, however, is that proper cost-benefit analyses be undertaken before those saddled with the responsibilities present these as options to potential users especially for enhancement purposes. Society should also be educated to know that medicine as a whole and psychiatry in particular are imprecise sciences. In psychiatry, mind parameters are dynamic with the environment and advertisements and other social pressures are some of the relevant factors in self, need, and mood perceptions.

In many countries, enhancement medicines are now consumerism driven, yet drugs that have been so offered are sometimes found dangerous years later. Examples include SSRI that are now regarded as dangerous decades later and benzodiazepines which now have problems of epidemic iatrogenic addiction. Often, somehow, some of these challenges become well known only after drug patents have expired (Pieters and Snelders 2009). Obviously increased stringency in the conditions of making enhancement drugs available and education to make the public more wary are important responsibilities of all concerned.

At social levels, it can be argued that wariness over the advantages of these forms of enhancement is inconsistent with the usual practice of other ways of enhancing opportunities, for instance, by getting the best school possible for children and a regular workout regime that builds one’s body. These methods that enhance through natural mechanisms can usually be differentiated from those that are imposed by the use of chemicals or technology from without because unlike the latter, the former are harmonious and enduring forms of gain in the body.

Would enhancement not make the strong relatively stronger and the weak relatively weaker in society? It likely would but that in itself would not be unethical unless it gets to a point when socially desirable goals are missed demonstrably because of it or socially undesirable states occur because of it. Normally, enhancement is a product of affluence (Elliott 2004). The wealthy also should not be punished just for being so; wealth may have a price which the poor are “unwilling” (Granat 2003) or unable to pay. In any case these social issues raise ethical issues mostly when advantages taken are undue, the process or outcome of enhancement endangers others, or resource allocation is unacceptably skewed.

One of the most relevant applications of neuroethics in the world of the neurosurgeon relates to the growing specialty of altering abnormal and normal states with the use of psychosurgery or deep brain surgery. The advent of deep brain stimulation (an impermanent treatment), as opposed to lesion making (a permanent treatment), has made it easier for surgeons to recommend and patients to accept surgical treatment that alters neurophysical and psychological functions. Society is still appropriately mindful of functional neurosurgery and its abuses decades ago (Freeman 1958). The question we all must ask is: Is society ready for increasingly sophisticated interventions which may soon be able to alter normal functions or alter states of mind? Recent qualitative research has shed some light on this issue. A number of studies have shown that both patients and surgeons will accept deep brain surgery for pathological states such as depression or eating disorders, but find ethically dubious its use for enhancement of normal states (Mendelshon et al. 2010, 2013 Lipsman et al. 2011). In another study, patients were willing to accept treatments that may alter identity if it was the only response to threat to life, but they considered procedures to alter a normal state as ethically dubious (Lipsman et al. 2009). All these ethical issues are compounded by additional challenges like informed consent, which in this setting will often be required to be obtained from patients who are cognitively and/or psychiatrically compromised (Grant et al. 2013; Lipsman et al. 2010). Such professional and scientific investigation will go a long way in reassuring society that due diligence is being done to ensure that mistakes of the past are not repeated.