Cognitive enhancement debates: from conceptual to empirical explorations

Neurostimulation is the latest iteration of the human enhancement debate. It follows a lineage of emerging biotechnologies that have inspired speculations and interest in employing them to enhance the cognitive functioning of human beings. Previous and ongoing discussions on cognitive enhancement revolve mainly around the use of drugs or gene modification. Like neurotechnology, these discussions respond to the potential of these biotechnological interventions to manipulate people’s physiological characteristics in ways that could improve their cognitive performances “beyond the species-typical level or statistically normal range of functioning.”Footnote ¹¹ Since the ethics of cognitive enhancement has been discussed in the context of specific biotechnologies, some advantages or worries may not apply generally to all types of biotechnologies. Here, we will focus on points relevant to DBS-enabled cognitive enhancements.

The main argument for developing and using biotechnologies to enhance cognitive performance is that enhanced cognition will likely improve people’s well-being and opportunity range. Improved mental acuity, like memory, concentration, and learning and processing new ideas, will expectedly improve people’s chances of living a good, flourishing life, especially in the brute conditions of struggle, misfortune, competition, and inequalities. Richard Dees summarizes this consequentialist, welfare-based argument for enhancements, pointing out how their positive effects are not limited to those who are enhanced but also the lives they affect:

The connection between improved cognition and well-being is intuitively plausible, and proponents of cognitive enhancement build their arguments around it. Smarter, sharper, quick-witted, and confident people are expected to navigate and thrive better in our complicated world as well as contribute valuably to the welfare of others through their interpersonal interactions, contribution to knowledge production, and sophisticated ideas of improving our living conditions. For these reasons, cognitive enhancement is embraced as an important good and the value of beneficence calls for its realization.Footnote ^13, Footnote ¹⁴

Critiques of cognitive enhancement are more complex, encompassing a wide range of objections. They can be understood as problematizing any one of the following aspects: (1) the goal of enhancement, (2) the means of enhancement, and (3) the consequences of enhancement. The first kind of critiques challenge the underlying motivations and ends of enhancement technologies. Some critics have argued that suspect norms drive enhancement technologies. For example, Michael Sandel argues that the pursuit of enhanced human beings is motivated by a desire for perfection that is not only unattainable but denies the giftedness of human life.Footnote ¹⁵ Another prominent critique is that endeavors to enhance human beings seek to remove defining components of our humanness, such as the ethical significance of vulnerability as sources of meaning and relationship-building.Footnote ¹⁶ These arguments challenge the characterization that certain human limitations and vulnerabilities are deficiencies or pathologies that need to be mitigated or expunged through pharmacological or neurotechnological interventions.

The second type of critique challenges the means of enhancement. Enhanced cognition may not necessarily be an objectionable end, and if anything, it may be an important one, as reflected in our practices of education and healthcare. Instead, the problem lies in how cognitive enhancement is achieved. Even though both the processes of learning and neurostimulation may produce similar valued outcomes, for instance, a common reaction is that something important seems to be compromised when enhanced cognitive performance is produced passively via neurostimulation as opposed to through active learning and mental exertion. Various accounts try to explain this moral asymmetry, ranging from neurotechnology as an “unnatural” way to be enhanced to it being an unfair and “corrosive shortcut” that robs from the enhanced person any authenticity or responsibility for their accomplishments.Footnote ¹⁷

The third type of critique challenges the consequences of enhancement. As noted earlier, the main justification for enhancement technologies is that it will likely increase individual and social utility. But some have questioned this presupposition. One major worry is that enhancement technologies would likely exacerbate social inequalities. Enhancement devices would be expectedly expensive, and thus, the goods of enhancement would only be available to classes of people with the material resources to access them.Footnote ¹⁸ Others raise doubts that amplified mental capabilities—like memory, intelligence, and emotional control—would genuinely facilitate individual well-being, pointing out that there may be important utility in forgetfulness and experiencing negative emotional states.Footnote ¹⁹ Also, there are legitimate worries that cognitive enhancement may impose burdensome expectations on enhanced individuals that may detract from their well-being and sense of agency.Footnote ²⁰ These sets of arguments are critical of the common presumption that cognitive enhancement obviously promotes human welfare at both the individual and social level.

The ethical discourse of cognitive enhancement has primarily been engaged at the level of abstraction and theoretical speculation. This is understandable given that neurostimulation as a principal enhancement technology does not yet exist and assessing its ethical dimensions and implications is, in important ways, a futurist project. But Eric Racine and others have advocated for ethical analysis to take an “empirical turn” and look to psychology and social sciences to draw further insights and predictions. This is especially the case concerning the potential consequences of enhancement, where arguments are made about the likely effects of cognitive enhancement on human welfare and flourishing. So far, the arguments understandably have been more speculative and casuistic, with outcomes of neuroenhancement technologies inferred from other already existing interventions. For Racine and others, a more empirically informed discourse on the ethics of cognitive enhancement is needed. Since many statements supporting or opposing cognitive enhancements make claims about the social and psychological impacts of enhancement, the enhancement debate would inevitably be stalled without greater input and evidence from social and psychological sciences.Footnote ²¹

We, too, recognize the need for more empirical work to bear on the cognitive enhancement debate. But, in addition, we note that empirical work on cognitive enhancement to date has focused on individuals who identify as or are presumed to be cognitively typical. People with cognitive impairment or with intimate connections to people with cognitive impairment have not been significant contributors to the discourse on enhancement. Given the ways in which experiences with cognitive impairment can shape one’s perspective on the role and value of cognition, this is a significant gap. For this reason, we conducted qualitative studies to gather the perspectives of people intimately acquainted with the effects of dementia.

Before we discuss the preliminary findings from our qualitative study, it is first important to explore the idea of cognitive enhancement as a kind of transformative experience. Characterizing cognitive enhancement in this way may be a useful frame not only to interpret our preliminary finding but also point out the ways in which the cognitive enhancement debate could be stalled.

Cognitive enhancement and transformative experience

One idea we would like to explore is whether it is plausible to characterize cognitive enhancement as a kind of transformative experience. Transformative experience refers to the kinds of life-changing experiences that are (1) dramatically novel to the agent, (2) inaccessible to understand without going through them, and (3) can radically alter the perceptions and preferences of those who do undergo them to the extent that they might consider themselves as becoming a “different person.” First, an agent may have an experience that is considered transformative in the sense that it is so unlike their prior experiences that such an experience is novel; it does not resemble an agent’s antecedent experiences. Second, an agent could not have drawn from their past experiences or from the stories of others who went through the relevant experience to adequately grasp the character of the new experience prior to undergoing it, which makes it epistemically inaccessible. Third, since a transformative experience exposes an agent to new epistemic content, especially when the experience stems from changes in an agent’s embodiment or social position in the world, it can significantly change an agent’s interpretive lens and their scheme of values from which they make judgments. For these reasons, these experiences can be transformative in both the epistemic sense (it gives the agent new information in virtue of the experience) and personal sense (having that experience changes an agent’s core beliefs and values and their subjective sense of being).Footnote ²² Paradigmatic examples of transformative experience include having a child, going through puberty, choosing a new career, becoming disabled, and transitioning to different gender from what was assigned at birth.Footnote ²³ These are considered transformative because they can alter people’s subjective point of view in ways that are so unique and profound that one could not have imagined or understood what it would be like to undergo such experiences, and consequently, these experiences may shift how people perceive the world and what they value.

Transformative experiences are philosophically interesting, and one reason why is that they pose an epistemic, decision-making problem. When confronted with a transformative choice, how are we supposed to make a rational decision when we lack a robust understanding of the options? L.A. Paul’s work has been influential in articulating and addressing this problem.Footnote ²⁴ According to Paul, a normative standard for rational decision-making is to weigh the options and choose the one that will bring about a state that has the highest expected value. When the decision is about our future, then a rational decision procedure is to consider and weigh the possible future states of being and choose the outcome with the highest expected utility. Attaching values to each possible future outcome involves imagining what it would be like for us to be in those future states. Yet the problem with transformative experiences is that they are epistemically opaque. For them, we cannot know what it would be like to be situated in that future state without actually being in that state. Therefore, we are not able to put a value on the outcomes of the choices prior to deciding. For Paul, this creates a challenge to the possibility of making a rational decision when it comes to transformative choices.

The epistemic challenges of transformative experiences are deeply concerning when we look at neuroenhancement technologies and how their moral justification often depends on inferring or imagining what it would be like to embody a certain state of being that these technologies create. If a neurotechnological intervention produces a state that is transformative, then it may constrain what claims we can make regarding the individual utility of that potential state of being. Is it plausible to conceive of cognitive enhancement as a form of transformative experience? This is a difficult question. At one level, it seems like the answer should be a negative. The experience of cognitive enhancement is wholly familiar. We think, feel, remember, problem-solve, make connections, and draw inferences and, if things are going well, sometimes we improve on these in various ways and to different extents. And even when we do not, it seems relatively easy to imagine taking these deeply familiar mental activities and amplifying them in one way or another, for instance, making us remember more, or recall more quickly, or learn and process information and draw mental connections more expeditiously. Viewed in this way, experiences of cognitive enhancement might seem to lack the kind of novelty that characterizes a transformative experience. Yet, at another level, describing the experiential aspects of cognitive enhancement as a mere extension of everyday cognitive activities seems unreasonably simplistic. However, the transformative potential of cognitive enhancement seems to depend on what capacity is being enhanced and to what degree cognitive enhancement could enable people to have experiences that are dramatically novel. Processing and retaining more information, or making more connections, or having a more expansive perceptual awareness may lead to qualitatively different experiences and perception of the world since we would be accessing content that we never had access to before. We will return to this discussion in Section “The “hard to imagine” problem: information deficit or transformative experience?”

If it is plausible to describe cognitive enhancement as a kind of transformative experience, then this would constrain what claims we could legitimately make about its effects on individual well-being and flourishing. It may also limit what kind of empirical work we can legitimately pursue to help inform the ethical discourse on cognitive enhancement. In the next section, we will discuss our qualitative study with people intimately acquainted with dementia, where we are studying their perspectives on certain kinds of cognitive enhancement. Their testimonies seem to lend some empirical support to the idea that cognitive enhancement is indeed a transformative experience, which then invokes the question of how we should proceed in exploring the ethics of cognitive enhancement.

Exploring the ethics of cognitive enhancement through hypothetical devices

We are conducting a qualitative study interviewing people intimately acquainted with dementia to inform the ethics of cognitive enhancement discourse. The interviewees are intimately acquainted with dementia in two ways: (1) they are people perceived to be at risk of developing dementia as determined by their family history or genetic testing and (2) they are or have been in intimate family relationships with PLWD. Given their adjacent experiences to dementia, we will often refer to the interviewees as “people living in close proximity to dementia.” We are inquiring about their perspectives on various forms of cognitive enhancement by presenting them with a range of hypothetical neural devices that might one day be used to enhance users in varied ways and gauging their views through a semi-structured discussion. This study follows a prevalent mode of inquiry in empirical ethics research of posing hypothetical cases to diverse publics to explore the plausibility of certain ideas or ethical desirability of certain options.Footnote ²⁵ The Pew Research Center recently conducted such a study to measure public opinion on the potential future uses of brain implants, posing the possible ways that neural devices could enhance certain cognitive capacities:

Exploring the ethics of cognitive enhancement by means of probing people’s moral reactions to hypothetical enhancement technologies is also closely connected to a broader methodological legacy in philosophy of using thought experiments in arguments. Briefly put, thought experiments are devices of the imagination that seek to elicit intuitive responses that are expectedly shared across various publics to serve as a reason to accept or doubt a particular thesis or idea. Think of classical thought experiments, like Judith Jarvis Thomson’s Violinist analogy,Footnote ²⁷ Phillipa Foot’s Trolley Problem,Footnote ²⁸ James Rachel’s Smith, and Jones thought experiment,Footnote ²⁹ among others. The function of thought experiments, according to Daniel Dennett, is to be “intuition-pumps” by invoking intuitive responses to often fantastical scenarios to isolate and test the plausibility of a concept.Footnote ³⁰ As such, hypothetical cases are useful in generating intuitions that affirm or call into question a particular thesis or concept.Footnote ³¹

Hypothetical neurotechnology cases, particularly when they are vivid and comprehensive, are effective vehicles for generating intuitions. Grant Gillett proposes that fanciful cases about implantable neurotechnologies are useful to “hone our intuitions” about human identity.Footnote ³² Kasper Lippert-Rasmussen argues that using far-off but more powerful hypothetical states of technology is a legitimate argumentative approach for two reasons: first, it allows a clearer exploration of conceptual problems, and second, current technology may not be ethically problematic at all but its future iterations may turn out to be problematic.Footnote ³³ These attributes seem to motivate researchers to turn to hypothetical devices to explore the ethical desirability of cognitive enhancement. There is a lack of philosophical consensus on what intuitions are (immediate, non-inferential responses to presented stimuli, considered judgments, or other) and how they function in argument (as data, illustration, heuristic, or other).Footnote ³⁴ Yet they clearly play a prominent role in philosophical argumentation.

Another important feature of our study is that we focus on a specific group—people living in close proximity to dementia. Intuitions are importantly situated and embodied, and different ways of being can lead to differences in how hypothetical cases are imagined, interpreted, and reacted to. Some people may be, due to their positionality, more attuned to certain features of a case that may be overlooked, misunderstood, or underappreciated by others who are differently positioned. This means that some intuitions should be attended to more closely or given serious consideration when it comes to understanding and addressing certain philosophical and ethical questions. To give one example, philosophers of disability have challenged the usefulness of the bare intuitions of non-disabled people to inform discourse about the nature of disability, especially its relation to well-being. They contest that the embodiments and/or experiences of nondisabled people sets limits to their moral imaginations, leading them to misattribute or exaggerate the harms involved in being disabled.Footnote ³⁵ Certain forms of experience confer epistemic advantage, making some stakeholders better positioned to inform a discourse than others through their testimony. Thus, it can matter whose intuitions we account for when grappling with certain philosophical and ethical questions. Our study worked from the premise that people living in close proximity to dementia may have the kind of experiences that afford them access to certain kinds of knowledge and insight that could valuably inform normative debates on cognitive enhancement.

In our study, we explore the perspectives of people living in close proximity to dementia by having them consider hypothetical neural devices and imagine what it would be like to use and live with them. In the construction and presentation of the hypothetical cases, we seek to present futuristic neurotechnologies that are realistic or believable and sufficiently detailed to enable participants to engage the cases meaningfully.Footnote ³⁶ We also select familiar cognitive abilities that most people typically exercise in their daily lives, e.g., memory, language, visuospatial skills. These abilities are also ones for which there are ready examples of people who possess them to extraordinary degrees, such as knowing someone with a photographic memory or someone with mesmerizing speaking ability or with a seeming preternatural knack for finding their way around physical spaces or tasks, or conversely people whose abilities are compromised, e.g., PLWD.

The hypothetical cases are posed to interviewees through the presentation of short videos that demonstrate the proposed cognitive ability and are accompanied by a narrator describing the enhancement and its potential real-world benefits. One example is a “memory device” to amplify a user’s short-term memory:

After the video is shown, we conduct semi-structured interviews asking participants to reflect on the devices presented and have an in-depth discussion about their views on cognitive enhancement, including whether they expect it would increase their subjective well-being.

One notable observation we have made thus far is how some interviewees struggle at times with the thought experiments, expressing difficulties of imagining what it would be like to be cognitively enhanced in the ways that the hypothetical cases pose.Footnote ³⁷ We observe people adopting different strategies to make sense of the hypothetical devices. For some interviewees, they simply ask for more details and clarification on the nature of the hypothetical devices. One person commented: “Do you get your short-term memory back for the last 24 hours and then it gets replaced by the next day? Or do you continue to remember it? Does it allow you to remember that you took your medication this morning, but not yesterday morning?” Another noted, “So how effective [would it be] and would it be able to, like stimulate different areas besides just short-term memory? Would it, you know, include memories of words or not?” Other interviewees turned to familiar examples in science-fiction to understand the hypothetical neurotechnology cases, such as relating it to bionic limbs or “… sci-fi movies where somebody’s wearing glasses with some kind of display built into them that identifies whoever’s walking up to them.” Others reached for analogies to other assistive devices to make sense of the hypothetical devices, such as pacemakers, hip and knee replacements, or cochlear implants, hearing aids.

We also came to recognize a kind of hesitancy that often emerged at some point in these interviews. The hesitancy came when people were asked to talk about how they personally might experience cognitive enhancement devices and whether they viewed these kinds of potential changes in themselves in positive or negative terms. What was often expressed was a difficulty in projecting what it would be like to be cognitively enhanced. This is nicely encapsulated in the response of one interviewee:

At some point, participants seemed to reach their imaginative limit with respect to hypothetical cognitive devices and were more reluctant to offer normative judgments about the devices or enhanced abilities. This sentiment was expressed in different terms, such as “It’s totally hard to imagine.” or “It’s hard for me to picture.” We refer to this common response as the “hard to imagine” problem.

In this section, we reviewed an important preliminary finding of our qualitative study of the perspectives of people living in close proximity to dementia about the ethical desirability of cognitive enhancement. The intended aim was to inform the ethics of the cognitive enhancement debate with the perspectives of stakeholders who might be more attuned to certain important features of the issue given how they are situated, especially in relation to the value and functional implications of cognitive abilities. This finding is that interviewees sometimes express difficulty in imagining what it would be like to be cognitively enhanced—we call this the “hard to imagine” problem. This raises the question of how we should understand this problem. In the next section, we will consider the idea that the “hard to imagine” problem is not necessarily the result of a methodological shortcoming of the study, but that cognitive enhancement may be a kind of transformative experience.

The “hard to imagine” problem: information deficit or transformative experience?

How should the “hard to imagine” problem be understood? One way is to see this as a methodological problem. That is, the design of the study may not provide the interviewees with the level of information or proper framing needed to enable them to imagine themselves cognitively enhanced and in turn limit their ability to anticipate how they would feel and respond were they to be in that circumstance. One could imagine such a methodological failure to have different sources. For instance, the video descriptions of cognitive enhancement devices might be inadequate to the task by not providing enough information for people to envision what cognitive enhancement by means of neurostimulation would be like. Perhaps more information about memory circuits and how stimulating them might change them is needed, as well as more information about human cognitive abilities and how they can change or better examples of cognition-dependent daily functioning. There are many ways in which the hypothetical devices could be presented differently. If the crux of the “hard to imagine” problem is due to a study design flaw of not presenting the hypothetical technology cases with the needed informational resources to help interviewees imaginatively project themselves as cognitively enhanced, then the empirical question of how to remedy this shortcoming in future iterations of this study or other studies is relevant. But this empirical question might be quite hard to answer. How much contextual information would be beneficial or needed? This is a familiar problem in anticipatory ethics.Footnote ³⁸ How are the scenarios to be crafted? What needs to go into them? How realistic do they need to be? How likely and how detailed do the possible outcomes need to be sketched so that people can or feel comfortable giving their normative judgments about them?

Yet there has been little attention given to a more fundamental question of whether employing hypothetical cases to invoke people’s intuitions is an effective methodology to explore the ethics of cognitive enhancement, especially when inquiring its impact on individual well-being. The attention of many empirical ethics studies is placed on what people think about cognitive enhancement devices—do they like them, do they find them morally problematic, what concerns do they raise, etc.—and not whether hypothetical devices are constructive means of ethical exploration.

This raises another possibility that is worth considering. Maybe what explains the “hard to imagine” problem is not necessarily that the interviewees have not been provided with enough information about the hypothetical enhancement technology but rather that cognitive enhancement is a kind of transformative experience. The reason why it may be difficult for interviewees to participate meaningfully in the study’s imaginative exercise is that a cognitively enhanced state of being is exceptionally novel and interviewees may lack any prior experiences that would allow them to grasp what it would be like to engage and experience the world with extraordinarily amplified cognitive capacities. The imaginative act of putting oneself in the place of a cognitively atypical embodiment can seem relatively straightforward. For example, in trying to imagine what it would be like to be a person with boosted working memory skills, someone might simply draw from their own personal experience of their own working memory, extrapolating from the frustration that one might often feel when forgetting things or having difficulty keeping track of information, and imagine a state where they could hold and organize even more mental items at the same time and for a longer period than they presently could. Yet, what we have found is that this kind of imagining of being cognitive enhanced is more complicated than it seems. Like various forms of disability, various forms of enhancement may be too difficult and abstract for people in species-typical embodiments to imaginatively grasp given how our moral imagination is constrained by our specific embodiments and the experiences shaped by them.Footnote ³⁹ Although acts of imagination are far-reaching, they are still, in important ways, bounded by our embodied experiences. If cognitive enhancement involves creating novel forms of embodiment and with it, new or unprecedented modes of engagement with the world, then imagining what it would be like to be cognitively enhanced may be too shaky and untrustworthy to undertake given how many of us are typically embodied, especially if cognitive enhancement involves perspectival and value changes that we just cannot clearly and reliably envisage.

If cognitive enhancement is indeed a transformative experience, then in some cases there is no amount of information that could be provided to the interviewees that would enable them to imagine what it would be like to be cognitively enhanced. To illustrate this point, consider LA Paul’s example of the experience of becoming a first-time parent. Prior to the experience, most of us may have a descriptive understanding of what a parent is and have encountered innumerable encounters and stories of it in our everyday lives, but we may never really understand what it would be like to be a parent without assuming the role. Given its social significance and how it can permeate our lives, becoming a parent is expectedly a radical shift in one’s situatedness and, in turn, one’s point of view. Moving through the world as a parent is expectedly very different from moving through the world as a non-parent, such as how a bustling city street is experienced (potentially hostile to children versus exciting and vibrant) or how an unseasonably hot day is interpreted (an ominous sign of climate change that may threaten their child’s future versus an annoyance). The point is that parenthood is a transformative experience in that it changes our perceptual experience, altering the valence of certain features of the world that someone may not, and even could not, recognize until they become parents. Thus, certain important aspects of parenthood are inaccessible or difficult to obtain without undertaking the experience.

It is worth considering whether cognitive enhancement is analogous to these transformative experiences. The epistemic hurdle faced by participants in studies of ethical views of cognitive enhancement may not be due to a lack of information but to perceptual limitations stemming from embodiment. That is, perhaps asking people to envision themselves living with far superior abilities, with whatever psychological and social complexity that entails, within their own limited embodied experiences may in certain cases be too much to ask. The changes related to cognitive enhancement might be transformative if they fundamentally alter a person’s place and orientation in the world so as to reconfigure how the world is perceived. Consider how atypically extended cognitive skills—such as the memory, language, visuospatial, or other cognitive skills inquired about in the study—might change the way that people experience the world. Someone with a photographic memory, or the chess skills of a grand master, or the verbal eloquence of Shakespeare, would likely experience, interpret, and engage the world differently. How someone values an interaction with a stranger may shift if they could remember every detail of that interaction for days or months after. Friendships and other significant relationships may change if someone approached their conversations as opportunities for demonstrating eloquent prose, such as leading to feelings of alienation.Footnote ⁴⁰ Walking into a house with dramatically enhanced visuospatial skills might produce an overwhelming desire to remodel or decorate. Such worries about cognitive enhancement are lent credence by the clinical descriptions or first-hand testimonies of people with superior cognitive abilities, such as hyperthymesic syndrome or highly superior autobiographical memory. For instance, Elizabeth Parker and colleagues describe the case of AJ who experienced her extraordinary autobiographical memory as a “burden”:

These considerations give us good reasons to take seriously the possibility that cognitive enhancement through neurotechnology might be a transformative experience, altering our embodiment in ways that would also likely alter our implicit frame of reference from which we interpret the world, form our values, and express our intentions. People may start to perceive the world in terms dictated by their enhanced cognitive abilities. What would that be like? Would they still value—or even pay attention to—the things they value now? If cognitive enhancement is indeed a transformative experience, then this kind of knowledge would not be accessible to the cognitively unenhanced. This may be the source of the “hard to imagine” expressions of participants: individuals might not lack information about a how device would work but they might be unable to imagine what it would be like to have these skills given how they are currently embodied.

If it is reasonable to characterize cognitive enhancement as a transformative experience to explain the “hard to imagine” problem, then there may be limits to what kind of empirical ethics research we can legitimately undertake to advance the ethics of cognitive enhancement discourse. Certain inquiries about cognitive enhancement, like its expected utility, may be well beyond the purview of empirical ethics. Does this mean that testimonies, particularly from certain stakeholders, cannot contribute valuably to the normative debate about cognitive enhancement? Are the perspectives of people living in close proximity to dementia not relevant to the debate? We will address these questions in the next section.

The place and value of testimony in the cognitive enhancement debate

The idea that cognitive enhancement is a transformative experience presents a serious challenge to ethicists who seek to bring empirical ethical work to bear on the ethics of cognitive enhancement debate. One of the implications of characterizing cognitive enhancement as a transformative experience is that qualitative studies that turn to stakeholders’ perspectives on the expected quality of life implications of cognitive enhancement may not actually help inform what would be the effects of cognitive enhancement to individual well-being. Moreover, it seems to undermine the relevance of testimony in the cognitive enhancement debate. Is there still value in looking to the perspectives of certain diversely situated stakeholders, as we are currently and others have done, to help illuminate how neuroenhancement technologies could alter the life prospects of individuals? After all, if cognitive enhancement can be a transformative experience, this calls into question who, if anyone, has the epistemic standing to speak authoritatively about its potentially transformative effects. Is the conclusion that must be drawn that empirical ethical projects that bring out stakeholders’ testimonies are normatively impotent to the cognitive enhancement discourse and should be abandoned?

This is too quick. Although cognitive enhancement may be a transformative experience, there is still reason to perceive stakeholder testimony and engagement as importantly relevant to the ethics of cognitive enhancement debate. Paul may be correct that in most transformative experiences, we cannot know whether we will likely be better off or worse off after the experience. Furthermore, we are unable to know how our perceptions and preferences might change after the transformative experience. However, this does not mean that certain publics cannot provide unique and meaningful insights that are relevant to gauging the expected utility of cognitive enhancement. For one, the ethical desirability of cognitive enhancement is, in important ways, shaped by how we understand and appraise the utility of our current embodied and socially situated cognition. What is it about our present circumstances—our vulnerabilities, our limits, and our possibilities—that excites the public imagination about cognitive enhancement? What are the probabilities and costs of not pursuing enhancements? In this respect, many of us can contribute to this discussion as informed by our own lived experience and from our diversely embodied, socially situated standpoints.

Yet we also want to suggest that certain perspectives, for example, from people living in close proximity to dementia, may offer important insights that are relevant to the ethical debate about cognitive enhancement and worth attending to. Although they may not have direct personal experience of undergoing cognitive enhancement, they do have personal experiences observing, interacting with, and caring about substantive cognitive changes in family members that many people do not, and this may serve as an epistemic asset and confer normative insight to the cognitive enhancement discourse. For example, care partners of PLWD are intimately acquainted with the effects of cognitive changes and cognitive decline. They are highly attuned to the varied ways in which the world is differently represented to PLWD and how it shapes their experiences and perceived horizon of possibilities in the world. This is intimate knowledge that is gained through their lived entanglements and negotiations with PLWD, allowing them to effectively support the agency of PLWD, anticipate issues that may come up, and accommodate or work with them in their pursuit of their conception of the good. This aspect of interdependence and mutuality is why [removed for review] describe care relationships with PLWD as a “shared agency.”Footnote ^42, Footnote ⁴³

The background experiences of people living in close proximity to dementia may serve as an epistemic asset in the ethics of cognitive enhancement debate. In one sense, it adds epistemic diversity to the overall discourse. Like most issues in bioethics, the normative debate around cognitive enhancement could be vitalized by more diverse perspectives to bolster innovation, robust thinking, and accountability. People living in close proximity to dementia may perceive cognitive enhancement in ways that are different from how people lacking such experiences might typically perceive it, indicating that the former are attentive to certain features of cognition that the latter would not necessarily be receptive to due to their limited experiences. For instance, living with someone who experiences anomia or paraphasia may lead one to become acutely aware of the structure and role of language in getting about in the world. Instances of calling a ball a “circle” or stalling completely over a simple word in the middle of a story are not just experienced as isolated mistakes of language. Families get a front row seat to how breakdowns in language can be sources of embarrassment, failed agency, and lost self-confidence for loved ones. It is a kind of special attunement to such instances that may privilege family members of PWLD when contemplating the potential effects of cognitive enhancement. Imagining how a cognitive enhancement device might improve self-confidence or self-efficacy might come easier to someone who has seen repeatedly the real-world implications of the opposite occurring for their loved one.

The underlying point is that there is still reason to take testimony seriously in the ethics of cognitive enhancement discourse even if we accept the idea that cognitive enhancement can be a kind of transformative experience. Adjacent experiences to dementia may confer an epistemic advantage, like a more well-rounded understanding of the effects of cognition on day-to-day function, rendering their testimony particularly relevant in speaking about the ethical desirability of cognitive enhancement. People living in close proximity to dementia may offer unique insights that could bear on the ethics of cognitive enhancement. What these insights could possibly be can only be brought out through more attention to their testimonies.