Accepting a helping hand can be the right thing to do.

Correspondence to Professor Arthur Caplan, Division of Medical Ethics, Department of Population Health, NYU Langone Medical Center, 550 First Avenue, New York, NY 10016, USA; [email protected] The underappreciated moral theorist Benjamin Franklin in his youth made up a list of virtues he felt ought to be followed as sound guides for living one’s life. Some of the virtues he prescribed relate to personal behaviour: temperance, order, resolution, frugality, moderation, industry, cleanliness and tranquillity. The rest are social character traits: sincerity, justice, silence, chastity and humility. He never abandoned his faith in those values, teaching them to his son and anyone who cared to read his Poor Richard’s Almanack. In his autobiography, Franklin tells us that he kept a diary in which he evaluated, on a daily basis, his success in living up to each virtue. That Franklin enjoyed a life in which the virtues he extolled were not omnipresent is well known. He would be the first to confess that there were more than a few occasions when he failed to live up to his own moral teaching. What is interesting about his virtue ethic is not his personal struggle to conform to it but his belief that moral character is made up of multiple components, that each person can, through intellectual struggle during one’s life, make real progress in changing the elements of one’s character for the better, and that failure is a constant companion with respect to self-improvement. Franklin is hardly alone in holding the view that improvement in the many dimensions of character is possible at every stage of our lives. Charles Dickens, Jesus, Socrates, Maslow and just about every high school teacher, religious leader and sports coach I have ever encountered believed the same thing. The idea that we are capable of constant selfimprovement may rest as much on normative belief as it does upon a series of sound, crosscultural, empirical studies, but it adds further heft to the crucially important argument brought forward by Singh. Her analysis of children’s views of the impact stimulant drug treatments have upon their self-governance is a seminal contribution to the ethical debate over the merits of treating children diagnosed with attention deficit hyperactivity disorder (ADHD) with drugs. Singh notes that critics of stimulant drug treatment worry that the use of drugs for the treatment of what might be labelled impairments of selfgovernance risks living children who lack the inborn capacity to self-govern. This worry holds that in controlling behaviour related to both performance in school or work and over-aggressiveness towards others, children receiving drugs will either be made into compliant zombies or amoral weaklings. In the absence of medication, and having failed to master their personal demons, both categories of child will be forever incapable of self-governance. As Franklin might have noted, human beings, despite a lot of rhetoric to the contrary, are more often than not incapable of self-governance in some aspect of their lives. Even the most determined amongst us often require help, reinforcement or even temporary paternalistic intervention to be autonomous. Exercising self-control is never easy. Developing the capacity to do so is very complex. Singh notes that her extensive systematic interviews with children receiving stimulant drug treatments provide a wonderful opportunity to determine how they see themselves on and off medication since they are on and off frequently for a variety of reasons. The results of her inquiries produce a body of evidence that should shame anyone who insist that drugs are only used to zombify children. The children report much benefit and very little negative impact upon their ability to self-govern. Indeed most children seem to feel empowered to be more self-determining when on medication than they think they are when not. Nor does the worry that self-governance cannot be formed in children who are given drugs to tamp down their aggression or to help them pay attention find support in her findings. Authentic moral agency and self-governance seems more capable of being developed in young people when they are not utterly distractable or trying to clobber their peers for no good reasons. Self-governance may well need to be constantly forged against the temptations of vice, as Franklin believed, but children who cannot pay attention at all, or who are hated and shunned by their peers because they are unpredictably aggressive, are at grave risk of not developing rich selves, much less the ability of self-governance. Those who see drugs as a temporary fix do not see that a temporary, easily reversible fix can and (as Singh shows), does lead to a permanent improvement. There certainly are ethical issues that require more debate. Are the number of children on drugs too high or too low in various parts of the world and why? Are the profits made from the sale of stimulant drugs so vast that there is a lack of interest in finding non-pharmaceutical interventions to help children with behavioural disorders? But the battle over stimulant therapy for attention deficit disorder (ADD) has been fought over their power to distort and stint the development of an authentic, self-determining self. The evidence of efficacy found in Singh’s interviews ought to calm these fears. Franklin’s analysis of self-governance reveals a complex set of traits which may require support and involve frequent failure even in the strongest of persons. Singh’s study shows that stimulant drugs can assist in children forming and exhibiting self-determination leading to persons with more not less capacity for autonomy and choice.