When an anxiety-reducing drug with virtually no side effects is used to enhance performance, is that cheating? Is it drug abuse? Is it an admission of professional weakness? During a series of three performances, a trumpet player in a professional orchestra consistently plays a difficult solo passage flawlessly each time. Her colleague in the trumpet section marvels at her ability to play so well, since he knows that he and other professional players are unlikely ever to play that particular passage with consistent perfection. His assessment of his colleague's luck and talent changes, however, when he learns she takes ten milligrams of the drug propranolol before each performance that requires her to play difficult solo passages. Although many people will agree on what constitutes ethical and unethical use of certain types of drugs, some kinds of drug use do not fit easily into either category. The patient who demands an antibiotic for a viral head cold, the athlete who requests steroids to enhance his or her performance, or the child who receives growth hormone injections because of a perceived social advantage to being tall present instances of drug use that are difficult to evaluate from a moral perspective. Propranolol for performance anxiety represents another instance of ethical ambiguity in regard to drug use. The reason for such ambiguity is that the ethical evaluation of drug use is shaped by cultural beliefs and values, many of which lie hidden in commonsensical, unquestioned assumptions we make about our world. These implicit meanings, when they surface, often are in the form of vague images and incompletely articulated ideas. Furthermore, cultural images may have competing and contradictory meanings that add to the ambiguity of a moral evaluation of drugs and their use. Propranolol use by musicians is an interesting case study for several reasons. It is a drug that can enhance one's performance and may increase one's advantage in the competitive field of the performing arts. As such, its use gives rise to moral questions similar to those raised by the use of steroids by athletes, such as fairness, or harm to the individual.[1] In addition, ambiguity about the meaning of performance anxiety and propranolol use complicates the moral issues. Is performance anxiety a normal phenomenon, as most musicians believe? At what point does it become pathological? Does the fact that physicians prescribe propranolol to treat performance anxiety confer upon it the status of disease? Or does the fact that musicians often obtain this prescription drug from their friends and take it before any important performance constitute simply another form of drug abuse? Propranolol and Performance Anxiety Performance anxiety, or stage fright, has been defined as "the experience of persisting, distressful apprehension about and/or actual impairment of, performance skills in a public context, to a degree unwarranted given the individual's musical aptitude, training, and level of preparation."[2] Propranolol is a prescription drug increasingly used by symphony and opera musicians to eliminate symptoms of performance anxiety. The drug was first introduced for the treatment of angina pectoris, and later used to treat cardiac arrhythmias and hypertension and to prevent sudden death after myocardial infarction. Propranolol use was later extended to treat migraine headaches and symptoms of anxiety associated with stress.[3] When a person is under stress, the sympathetic nervous system produces adrenaline-like chemicals that attach to beta-adrenergic receptor sites of the body. These sites produce physiological responses in heart rate, skeletal muscles, blood vessels, and bronchioles of the lungs and, in essence, prepare the body for a "fight or flight" reaction. Propranolol and other beta-blocking drugs compete with the adrenaline-like chemicals for these sites on the cells and block their physiological effects. …