This study examined discourses on the non-medical use of MPH by college students in the print media, bioethics literature, and public health literature. We found that there were three distinct paradigms used to describe the non-medical use of MPH. The "lifestyle choice" framework expressed in the print media generally reflected the opinion that the uses of neuropharmaceuticals for self-improvement is a laudable goal and a personal choice. The "prescription drug abuse" framework found in the public health discourse views the non-medical use of neuropharmaceuticals as illicit and a public health problem. The "cognitive enhancement" framework in bioethics discourse focuses on the ethical issues arising from presumed benefits of non-medical use of neuropharmaceuticals by healthy individuals. These paradigms were reflected notably in the headline content across discourses and the statements used to describe the non-medicinal use of MPH itself (Table 3). The lifestyle paradigm is also well illustrated in the print media's use of lay designations (Table 2) and the enthusiastic terms used to describe its potential beneficial enhancement effects of non-medical use of MPH (Table 3). We observed diverging claims about the frequency and acceptability of such MPH use. The print media provided overall detailed descriptions of whom, where, and when MPH was used non-medically and also how students were procuring it. The ethical discussion surrounding the non-medical use of MPH was without surprise more comprehensive in the bioethics literature. Overall, discussion of ethics was wide-ranging and only in the public health literature was there a clear stand against non-medical uses of MPH. Issues most frequently discussed concerned social aspects as well as safety considerations of the non-medical use of MPH for performance enhancement. Major areas of debate included whether performance enhancement with MPH was considered cheating as well as whether the phenomenon created injustices and inequalities. Discourses converged on the topics of overprescription of MPH and lack of reliable scientific data for the enhancement effects of MPH. Recommendations ranging from calls for legislation to increased public education were identified in all three sources of discourse but challenges to these recommendations were only identified and discussed in the print media and in the bioethics literature (Table 5).
As with most qualitative research and discourse analyses, some aspects of our study limit the generalization of the results. First, the small sample size and limited sample composition, in spite of broad searches and the use of multiple databases, are not exhaustive of all discourses on non-medical use of MPH. The results of this small study should accordingly be viewed as a preliminary step to fulfill this larger goal. Second, the scope of the study was limited to a few countries, mostly because of the available sources of the literature. Third, the specific case of the non-medical use of MPH was examined even though there are other drugs that are used in similar ways. However, this choice is supported by the draw of MPH for performance enhancement as reported in a recent survey published in Nature  and its well established use by university students . Fourth, the reported statements in the print media articles are an amalgamation of opinions from people interviewed by journalists and do not necessarily reflect the opinions of journalists. Accordingly, the print media content should be viewed as what was available to the public through this channel rather than the voice of journalists per se.
Disagreements between paradigms could have important healthcare, ethics, and social implications and consequences
The dissonance we observed between paradigms used to describe and evaluate the non-medical use of MPH for performance enhancement could have profound healthcare, ethics and social implications and consequences. Each paradigm carries forward a distinct view of the acceptability of MPH non-medical use. Speaking of a "lifestyle choice", a "cognitive enhancement", or a "prescription misuse" matters for scholarly biomedical ethics, public debate, healthcare and public policy. A major source of disagreement and concern is the unbalanced presentation of the potential positive and negative effects of MPH across discourses. In the print media especially, a fair number of potential adverse effects (Table 3) are mentioned but most often without qualification or quantification. In contrast to the risks, the positive effects are discussed using sensational terms like "wonder drug" or "smart drug" (Table 2). As suggested by Rajczi , such enthusiastic discourses about new technologies can arise from society's assumption that they are intrinsically valuable but can be independent of the scientific evidence. Furthermore, Lanni et al. argue that: "From a pharmacology point of view the fact that a drug is clinically used to treat an attention disorder or a cognitive problem does not necessarily mean that a high level of the relevant molecule would produce a high performance in a normal individual" . To date, the benefits of cognitive enhancement for healthy individuals appear to be based on media reports and a few scientific studies. However, the alleged efficacy of cognitive enhancers is an important area of disagreement and diverging perspectives.
Before rallying behind cognitive enhancement and most definitely before any kind of regulation or approval is put forward, current scientific data must be assessed and interpreted carefully beyond general assumptions inherent in terms like "cognitive enhancers" and "smart drugs". Contrary to some implicit assumptions found in bioethics and media discourses, there are actually only a few studies on the enhancement effects of cognitive enhancers on healthy individuals. The findings of these studies may in fact be limited in their potential to be generalized and support favorable opinions toward the cognitive enhancement of healthy individuals. For example, Elliott et al.'s often-cited, double-blind, placebo-controlled study showed that methylphenidate positively impacted performance on spatial working memory and planning but not on attention and fluency tasks. However, the results also showed that methylphenidate did not enhance performance tasks that were already learned . The study conducted by Mehta et al. investigated changes in regional cerebral blood flow as an indication that methylphenidate enhances spatial working memory . Barch et al. obtained results similar to the findings of Elliott et al. and Mehta et al. that amphetamine enhanced spatial working memory . In contrast to the three previous studies, Bray et al. reported that methylphenidate does not enhance the cognition of sleep-deprived individuals . Farah et al. recently examined the effect of Adderall upon creativity, a component of cognition stimulants are suspected of stifling, in a double-blind, placebo-controlled trial . They found that the drug indeed enhanced creativity on specific tasks but the amount of enhancement depended upon the baseline performance of individuals: lower-performing individuals were more enhanced than high-performers. The conflicting and fragmented results of these few studies currently provide limited support for the enthusiastic portrayals of cognitive enhancement.
To date, the studies supporting enthusiastic media and bioethics discourses do not reflect the reality of research on MPH-based enhancement. Several aspects of early research need to be further examined and reproduced. First, generalizing results at this point is imprudent given the small and homogeneous cohorts involved. Samples in these studies range from ten to twenty-eight participants and most of them are young healthy males. Current parameters cannot account for variable efficacy in individuals which would result in certain types of individuals being unable to enhance themselves thus perpetuating the debates on justice because of unequal effects. Second, the specific experimental nature of the tasks used for research does not necessarily reflect real-world performance in complex contexts. Further, Farah et al.'s results show that there may be an "enhancement ceiling" for certain types of individuals or tasks. Third, there is limited understanding of the long-term effects of MPH and other drugs used for enhancement. Presently, for treatment with MPH lasting more than four weeks, it is strongly recommended that the treating physician regularly reevaluate the necessity for the prescription for MPH . The survey on cognitive enhancement conducted by Nature revealed that respondents used cognitive enhancers on daily, weekly and monthly bases in almost even proportions  which indicated that enhancement may become a habit. In the laboratory setting, MPH has been shown to have an abuse potential under certain conditions [11–14] that may result in addiction with regular use of cognitive enhancers. In contrast to enthusiastic media and bioethics discourses, these observations have the potential to show that non-medical use of MPH may be less valuable than some expect because of the scientific and medical limitations of the drug effects.
The reported positive effects in the print media are largely based on anecdotes and are typically not adequately contrasted with scientific data about the effects of MPH on the healthy brain. Given these features, some enthusiastic interpretations found in print media as well as bioethics discourse could contribute to the unintended dissemination of a poorly understood non-medical use of MPH for performance enhancement. However, if public health discourses prematurely condemn this practice as a form of drug abuse, future public health strategies risk being ill-equipped to tackle the enthusiasm and interest for cognitive enhancers found in other discourses and perhaps in the public.
Bioethics and the print media need to sustain public information and socially-informed public debate
Bioethics discourse and, to some extent, the print media, contained extensive discussions on the ethics of the non-medical use of MPH. Nonetheless, our results suggest that the coverage of the phenomenon in these discourses brings about sources of confusion. For instance, there is a wide range of uncertain claims about the prevalence and risks of the practice. The print media, in particular, conveys in many respects more sociological details and context (e.g., who, how, when and where) regarding the non-medical use of MPH for performance enhancement. However, this may have unexpected consequences such as increasing the prevalence of the practice. In fact, the combination of consumption details and student testimonials with positive portrayals of the performance enhancement potential of MPH in the print media may incite individuals to engage in the practice.
Our results also suggest that using MPH for enhancement is already considered an integral part of social practice in some discourses. They show that some media reports consider MPH comparable to "traditional" methods of enhancement that are acceptable such as consuming caffeine. Combined with praise of MPH as a "miracle drug", this perceived social integration can build additional fervor for cognitive enhancement. This perception may be a reflection of the social context in which cognitive enhancement is emerging and would need to be captured in the bioethics discussion. Recent work on the medicalization of sleep and non-medical uses of modafinil has linked the acceptability of pharmacological enhancements to the context of use . In his book Listening to Prozac, Kramer postulates that: "The operational definition of wellness must be in relation to the demands and goals of society, here and now" . Not only does social context first modulate the definition of health on the treatment-enhancement spectrum but it also affects other issues. For example, coercion of individuals to use cognitive enhancers is often cited as an issue in the literature [3, 40, 48]. It was also identified as an important issue in our present discourse analysis. However, the specific nature of coercion remains vague without an indication of what causes this coercion and what stakeholders stand to gain. Both of these aspects are partly shaped by social context and are important to consider in ethical discussion and policy. However, critical outlooks on social context could pose a real challenge given the favorable opinions of influential bioethicists who emphasize the role of personal choice and individual rights in the choice to enhance cognition . Even though we found some aspects of media and bioethics discourses to be favorable and enthusiastic, they can also serve as important venues to voice attitudes and informing the public of the risks associated with neuropharmaceuticals.
The nature of information disseminated to the public is also of the utmost importance. There are potentially some valuable lessons about reporting on non-medical uses of MPH and other pharmaceuticals that can be gleaned from the guidelines put forth by the Australian Press Council. The Council's guidelines relate to journalistic reporting on illicit drug use (drug addiction). They recommend avoidance of reporting "stories that might excite the interest of young people in drug experimentation, including the naming of dangerous drugs". The recommendations for reporting on addictive drugs also state that "the harmful effects of any particular drug should not be exaggerated or minimized"; and that we should "avoid detailed accounts of consumption methods, even though many young people are generally familiar with them." The recommendations also "guard against any reporting which might encourage readers' experimentation with a drug, for example highlighting the 'glamour' of the dangers involved" . Though using neuropharmaceuticals to enhance cognitive performance happens in a different context than illicit drug abuse they do share some similarities. The thinking behind these guidelines could translate into avoidance of narratives and salient practices related to non-medical MPH by students as well as other forms of non-medical use of prescription drugs. This represents a strong stance that could appear paternalistic and an interference with good reporting practices but the onus of responsible reporting does not lie exclusively upon journalists. There are various stakeholders that could positively contribute to the ethical deliberation on cognitive enhancement and several reasons why their input would be beneficial. For instance, healthcare providers being interviewed on this topic may want to be vigilant about the opinions they express to journalists about non-medical practices especially regarding risks and benefits. For example, we found a clinical psychiatrist that was quoted as saying "Caffeine is fine. This is better (...) Students are able to accumulate more information in a shorter time frame. These drugs keep you awake longer. They minimize fatigue and help maintain a high performance level" . Perhaps healthcare professionals should be careful with such public comments on non-medical uses of pharmaceuticals. Public health agencies must also be aware of enthusiastic media reports if they want to counterbalance unwarranted messages in the media and better inform the public and stakeholders. These are some initial venues to explore to improve the commitment to public information and informed debate on non-medical uses of prescription drugs for enhancement purposes.
Beyond the improvement of journalistic practices and the responsible involvement of healthcare providers in stories about the non-medical use of MPH, broader public engagement needs further consideration given the stakes. Though the decision to use a neuropharmaceutical for cognitive enhancement may be up to the individual, the effects of the enhancement loom much larger. The choices of individuals may impact collective behaviors which clearly makes the subject of cognitive enhancement a public matter. However, public engagement is more than just informing the public. It is also listening to public voices. Racine et al. have proposed a model where inquiry and debate on a given scientific development is at the center of multi-dimensional communication between the scientific community, humanities and social science, the media as well as the public and stakeholders . With this model, knowledge about advances in neuroscience (or other branches of science) does not end when it reaches the public. Instead, public perceptions and opinion are fed back up the chain of knowledge to instruct the scientific community about what the public has understood about its work. Possibly the most interesting aspect of this model is that there is also dialogue between other stakeholders. The multi-directional aspect of models like these pave the way to engaging stakeholders in ethical discussion of cognitive enhancement to provide a richer and broader spectrum of perspectives.
Medicine, healthcare, and society need to prepare for broader and more prevalent non medical uses of pharmaceuticals
In our study, public health discourses on enhancement raised many concerns about the non-medical use of MPH for performance improvement because of its potential health consequences. The prevalence of this practice with MPH, which ranges from 3.2% to 11%, [51, 52] is worrisome from a healthcare perspective since it involves the use of a controlled substance by individuals outside of the intended clinical context. This trend has the potential to pave the way for the general acceptability of non-medical uses of other pharmaceuticals. Accordingly, societies could be faced with serious public health challenges before the ethics of this practice is properly discerned and publicly debated. The 2007 report on enhancement from the British Medical Association discussed whether a role for public health was timely but did not conclude on the subject . We did note that wide ranging solutions were suggested to prevent the expansion of the non-medical use of MPH for enhancement purposes (Table 5). Development of legislation on non-medical uses and distribution of prescription medications as well as the education of healthcare professionals and the public about the dangers of misusing prescriptions were common suggestions. It should be noted that possession of a prescription drug without permission and trafficking can have criminal implications but this has not discouraged non-medical uses for performance enhancement. Furthermore, students who feign symptoms of AD/HD can acquire legitimate prescriptions for non-medical motives.
This situation mirrors to some extent the widespread illegal provision of human growth hormone (hGh) in the US . The recent recommendations in Olshanky and Pers' paper regarding this practice focus mostly on the illegal distribution of hGh by manufacturers but also highlighted the ethical responsibilities of healthcare professionals. Though the stakeholders in cognitive enhancement with neuropharmaceuticals are different than in hGh, there appear to be similar problems with fraudulent sales online and trafficking of MPH among students [37, 63]. Prevention of these types of distribution, stricter prescription practices, better patient prescription compliance and effective, balanced information to the public could help decrease prevalence and social integration of the practice in the absence of medical, social, and ethical consensus about its acceptability. Regulatory bodies and policy makers could begin examining the hGh recommendations as well as their associated challenges to model potential action with regard to the emerging practice of the non-medical use of MPH. However, before any new policies are made there clearly needs to be a broader debate on the non-medical uses of neuropharmaceuticals in order to sort through ethical and social issues.
At this time many consider that the non-medical use of MPH for cognitive enhancement happens outside the confines of medicine. Physicians and allied healthcare professionals could be eased out of their role as "gatekeepers" to these types of drugs as suggested by Chatterjee . Unfortunately, it is not well-known if all healthcare providers are aware of the prevalence of the non-medical use of methylphenidate and other neuropharmaceuticals for enhancement or if they would feel concerned at all. Data from the US National Institutes of Health shows that over 40% of healthcare providers have difficulty addressing the subject of prescription abuse with their patients. For physicians, the subject of prescription abuse appears to be even more difficult to tackle than stigmatized conditions like depression and alcoholism . A survey of general practitioners on the subject of enhancement with pharmaceuticals in the Scandinavian Journal of Public Health indicated that general practitioners were not open to the use of prescriptions for enhancement purposes . These results suggest that healthcare providers are not fully aware of the prevalence of the non-medical use of pharmaceuticals for enhancement and that they potentially perceive enhancement to be outside the boundaries of medicine and perhaps out of their professional role. Even though some areas of medicine may consider cognitive enhancement to be outside of the realm of healthcare, some aspects of the phenomenon may call for public health interventions. This creates a vexing situation where healthcare providers' view of cognitive enhancement as a non-medical practice could curtail consideration of its public health implications. However, even when the pills are obtained on the black market they still, most likely, were paid for by some patient's health insurance. Consequently, the use of medical personnel and financial resources for cognitive enhancement of healthy individuals could be putting a strain on healthcare systems. Viewed in this light, users of cognitive enhancers may actually be inviting public health action and policy by consuming medical resources.
Currently, public health action for the prevention of the non-medical use of pharmaceuticals for cognitive enhancement faces some important challenges. First, it is important that healthcare professionals become more aware of the non-medical use of pharmaceuticals for cognitive enhancement. This would likely make them more comfortable discussing the topic. Second, the burden of responsible management of prescriptions may well fall on healthcare professionals and patients alike but the reality is that healthcare providers have little or no control over what is done with prescriptions when patients leave their offices. Public health information campaigns trying to prevent prescription misuse could perhaps more directly target enhancement uses of prescriptions. Lastly, in raising awareness among the public with regard to cognitive enhancement public health faces a possible conflict of values. On one hand, public health action aims to prevent practices that are potentially harmful to the public's health like taking a pharmaceutical without a prescription. On the other hand, raising awareness may inadvertently promote forms of cognitive enhancement of healthy individuals. Public health interventions will need to carefully consider how to play a role in cognitive enhancement.