In 2009, the Ethics, Law and Humanities Committee of the American Academy of Neurology (AAN) issued guidance regarding responding to requests from adult patients for neuroenhancers.1 The AAN report defines this term as “prescribing medications to normal adults for the purpose of augmenting their normal cognitive or affective function.” The author, Cynthia Geppert, has previously summarized the content of the AAN paper in a Psychiatric Times podcast available at http://www.psychiatrictimes.com/podcasts.
Recent articles in both The New Yorker2 and Nature3 confirm the widespread use of cognitive enhancers, especially among students and academics. Prevalence is a pragmatic but not necessarily an ethical argument. The most controversial aspect of the guidance is its underlying assumption that a valid goal of medicine is to improve the executive function of individuals who have no “diagnosable mental health or medical condition.”
There has been considerable commentary on the topic of the report in the neurology journals and bio-ethics blogs—most of it favorable—although there have been some essays of caution.4-7 There has been surprising little discussion in the psychiatric community, where a broad and morally serious dialogue on the subject of cosmetic psychopharmacology has not occurred since Peter Kramer’s prescient Listening to Prozac.8 The one notable exception is a Medscape news report on a presentation Derryck Smith, MD, made at the 60th Annual Conference of the Canadian Psychiatric Asso-ciation in September 2010.5
Since patients are already taking these medications, and we as psychiatrists are familiar with the utility of the drugs for clinical indications, Smith argues that it would be in the best interest of patients if psychiatrists prescribed neuroenhancers in a medical setting. The article quotes Smith as saying, “I am absolutely fascinated that the neurologists are in this game before psychiatrists. Psychiatry should be at the forefront of this because these are all medications that we use on a regular basis.” He refers to the guidance of the AAN as supporting the safety, ethics, and reasonableness of prescribing these medications if they will benefit patients. He concludes, “So psychiatrists are at liberty to use these medications as they see fit with fully informed patients.”
In this article, we present a counterpoint to Dr Smith’s position, and indeed to the application of the AAN guidance to psychiatry. We argue on the basis of core concepts in psychiatric ethics that psychiatrists should not at this time prescribe neuroenhancing medications for patients who lack clinical indications for these drugs.
John is a 25-year-old college junior enrolled in a premedical program at a prestigious university. He comes to a private practice psychiatrist requesting methylphenidate(Drug information on methylphenidate) to sharpen his study habits in preparation for the upcoming Medical College Admissions Test (MCAT). The psychiatrist performs a thorough psychiatric evaluation of John and determines that he has no personal or family psychiatric history that would contraindicate the use of a stimulant as a cognitive enhancer. John has researched the medications extensively and appears to be quite capable of providing informed consent.
The psychiatrist prescribes methylphenidate, 10 mg PO bid. John returns a month later reporting no psychiatric or medical adverse effects. John indicates that his cognitive stamina and focus have increased but this has not resulted in more productive studying because he has spent his extra mental energy obsessively organizing his study materials and memorizing flash cards. John requests that modafinil(Drug information on modafinil) be added to the stimulant to help him be more calm and deliberate about how and what he studies. John tells the psychiatrist his family has cultural expectations that he will become a physician but that his grade point average makes him barely competitive and he must score high on the MCAT to be seriously considered for medical school.
The harms of neuroenhancement can be broken into evidence-based harm and expected harm. The most notable articles regarding the evidence-based harm are the 2008 review by de Jongh and colleagues9 and 2 recent meta-analyses from Repantis and colleagues,10,11 funded by the German Federal Ministry of Education and Research. These articles present data from several studies that show statistically significant harm to healthy people (Table).
De Jongh and colleagues9 offer a compelling model to explain the harm. They propose “an inverted U-model, where performance is optimal at intermediate (prefrontal) catecholamine levels and impaired at levels that are either too low or too high. . . .” This model explicates how neuroenhancers may be beneficial for individuals whose performance lies on the ascending slope of optimal functioning while at the same time not benefiting, and potentially harming, those persons whose neurophysiology lies somewhere at the top, or worse, on the descending arm of the inverted U.
The studies show that “low memory span” subjects benefit more from neuroenhancement, while “high memory span” individuals may actually show deterioration. Finally, the evidence seems to indicate complex neuropsychiatric trade-offs beyond direct enhancements to the target cognitive domains that may have clinical significance. For in-stance, neuroenhancers may boost working memory to the decrement of longer-term memory and solidify the stability of memories only by compromising the flexibility of memory.9
In addition, expected harm can derive from the use of neuroenhancers in a psychiatric setting; in the short term there is potential for addiction with these drugs. Nonmedical use of stimulants in individuals with a genetic or environmental diathesis places them at risk for problematic use.12 Such a predisposition may not be recognized even in a sound psychiatric assessment.
In the long term, the prescribing of neuroenhancers will only intensify the current overreliance on medication management and encourage further neglect of evidence-based psychotherapeutic techniques in psychiatric practice and training.13,14 Psychotherapy has been shown to be equal or superior to pharmacotherapy for common problems such as insomnia and generally has fewer adverse effects than psychopharmacology.15 It is even more probable that the varied cognitive techniques and motivational and educational modalities subsumed under the rubric of performance psychology are less risky than neuroenhancers at this early stage of research and offer more enduring gains and transportable skills.16
Proponents of the use of neuroenhancers rightly emphasize that the relatively unknown risks and speculative benefits of the medications in healthy individuals warrant a rigorous and comprehensive discussion of informed consent. Ironically, these drugs may adversely affect the very competence required to provide informed consent for treatment.17 Neuroenhancers alter the attentional focus and working memory involved in the capacity to understand the risks and benefits of treatment; the cognitive flexibility required to reason regarding treatment and its alternatives; and the emotions, motivations, and valuations necessary to appreciate the impact of the treatment on the person’s life and values. Neuroenhancers might improve the ability of patients to provide informed consent; however, the drugs could just as easily diminish or impair that ability in ways that science cannot at this juncture reliably predict, which could result in liability issues yet to be determined.7
For psychiatrists and their patients, the seductive effect of both the desire for and use of neuroenhancers on voluntarism is the most concerning. John (the patient in our vignette) is surely able to understand the information presented and technically has full decision-making capacity. Yet John’s scenario discloses developmental, cultural, and psychological sources of influence, both external and internal.18 These influences call into question whether the consent John provides is truly autonomous and casts doubt on John’s ability to genuinely appreciate his situation and the short-term risks and long-term consequences of his request. We would argue that the use of neuroenhancers in healthy patients actually requires a “higher degree” of decisional capacity than does the prescribing of an SSRI for a patient with moderate depression.
And all should cry, Beware! Beware! His flashing eyes, his floating hair! Weave a circle round him thrice, and close your eyes with holy dread, for he on honey-dew hath fed, and drunk the milk of Paradise.
Samuel Taylor Coleridge “Kubla Kahn”
Even those who are advocates for prescribing neuroenhancers for healthy patients acknowledge the competitive nature of American society and that the drive and rewards for individual performance—especially in the military, academic, and medical professions—require the order of policy and the restraint of regulation to protect the rights of individuals.19
The AAN report makes the assumption that the discussion about informed consent will take place within the frame of a traditional physician-patient relationship. But as Smith correctly points out, cognitive enhancers are readily available online. This reduces the likelihood of the comprehensive psychiatric assessment and therapeutic alliance that are the pillars of psychiatric informed consent.
The participation of psychiatry in the burgeoning market for cognitive enhancers would be highly lucrative for the clinician but fraught with potential exploitation of patients. The international discussion about medicalization of normalcy and its relationship to the pharmaceutical industry also needs full disclosure in an informed consent discussion with patients who request psychopharmacology without a clinical indication.20
Promoters of cognitive enhancers will adroitly argue that the government and the medical profession have over the past decades determined that cosmetic procedures and augmentation therapies are encompassed within a broad understanding of the goals of medicine—and they would be right.21 These precedents explain why the AAN report con-cludes that the prescription of neuro-enhancers for competent adult patients without a neuropsychiatric disorder belongs in the ethico-legal category of permissible, with the clinical evidence and moral reasoning not supporting either outright prohibition or forthright obligation.
Permissibility is an abstract designation, and the AAN report recognizes that the act of prescribing neuroenhancers in concrete circumstances may be prohibited. We would agree that psychiatrists have greater expertise in the use of most neuroenhancing medications, but the more profound question is whether we, as a specialty, should be in the vanguard of their prescribing. A concatenation of contextual features at this stage of our evolution as a profession suggests we have other ethical obligations that take precedence.
As with many other elective and ameliorative interventions, such as some forms of cosmetic surgery, alternative and complementary medicine, and artificial reproduction, many insurance companies and employers will likely refuse to cover the costs of neuroenhancement. The government programs that subsidize much of mental health care have many more compelling priorities, thus bestowing the putative advantages of cosmetic pharmacology on the wealthy and privileged. Psychiatry has historically cared for those at the margins of society who already carry a burden of health disparities, economic disadvantage, and social stigmatization.22 The investment of our energies in the prescription of cognitive-enhancing medications could compromise that historic commitment to social justice. With a projected shortage of 45,000 psychiatrists and an expanding epidemiology of mental illness, is the use of psychiatric time and training to prescribe neuroenhancers for healthy individuals a violation of distributive justice?23
We must collegially respect if other branches of medicine accept cognitive enhancement as an ethically reasonable and even beneficent part of practice. There are, however, features of psychiatric ethics that distinguish it from other specialties, which may ground not proscription but prudence in entering the field of neuroenhancement. Radden and Sadler24 summarize these unique facets of psychiatric practice:
We have identified a number of intertwined aspects of the psychiatric setting each of which seems to contribute to separating psychiatry from other medical practices. These included aspects of the patient, symptoms and disorders, features of the social structures within which psychiatry is today practiced, including managed care systems; facts about the historical and cultural origins of stigma and controversy, and of aspects of the healing project, including its holistic focus, and the part attributable to the therapeutic alliance.
This distinctiveness suggests that psychiatry does have a significant and beneficent role to play in the ethical debate regarding the prescription of neuroenhancers for healthy patients. As experts in neurobiology, we can conduct and critically evaluate research to identify the short- and long-term risks and benefits of neuroenhancers for patients without recognized clinical indications. As members of a profession with a long legacy of philosophical sophistication, we are well suited to critically analyze the profound implications of medications, with the possibility of altering fundamental human ways of feeling, thinking, willing, and being.25