Should Psychiatrists Prescribe Neuroenhancers for Mentally Healthy Patients?

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.

CASE VIGNETTE

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 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 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.

Nonmaleficence

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