- BIOETHICS FORUM ESSAY
Prescribing Cognitive Enhancers: A Primer
Over the last year, the general public has learned a lot about the use of Ritalin and other psychotropic drugs by healthy people to improve alertness and concentration. And with that awareness there appears to be a growing acceptance, or at least resignation, as a series of recent publications strongly suggests.
Is it cheating for students to take a drug to enhance their ability to learn difficult material or stay awake to study for a big test? Maybe not, according to an influential and widely publicized paper in Nature last December.
“In the context of sports, pharmacological performance enhancement is indeed cheating,” wrote the authors, a group of leading neuroscientists. “But, of course, it is cheating because it is against the rules. Any good set of rules would need to distinguish today’s allowed cognitive enhancements, from private tutors to double espressos, from the newer methods, if they are to be banned.”
The authors continued, “We should welcome new methods of improving our brain function.”
Then, last April, an article in the New Yorker exposed the “underground world of neuroenhancing drugs.” Laying to rest any assumptions that this world is inhabited only by small fringe groups, the article said, “College campuses have become laboratories for experimentation with neuroenhancement…” Personal interviews with users and a review of the limited scientific literature supported the view that use of cognitive enhancers is not uncommon.
The number of people asking doctors for off-label prescriptions of brain-boosting drugs has reached such a critical mass that the American Academy of Neurology decided that doctors needed guidance on how to respond. A statement, which covers ethical, legal, and societal issues, appears in Neurology. It pertains to adult patients, which would include college students 18 year and older.
“This report and guidance should not be construed either to promote or discourage the prescription of neuroenhancements,” the guidelines say. But if doctors do agree to write a prescription, here’s how they can do so ethically:
- Tell patients that the medications have not been approved by the FDA for enhancing normal brain function and that there is a lack of evidence on their effects and risks on healthy people.
- Explain the possible side effects and risks, such as the chance of addiction from modafinil, a narcolepsy drug prescribed off-label to ward off sleepiness.
- Ask patients what they hope to gain from taking the drugs, such as becoming more competitive at work or school. “Clearly, specified goals, along with agreed-upon measures of success or failure, are particularly important when the long-term risks of neuroenhancement medications in normal patients are unknown,” the guidelines state.
- Explain alternatives to a cognitive-enhancing medication (including not taking it).
- Avoid or disclose conflicts of interest, such as owning significant amounts of stock in companies that make the drugs. “Neurologists who would potentially benefit from prescribing neuroenhancement to their patients…have an ethical obligation to so inform their patients,” the guidelines say.
The guidelines also offer some reasons for doctors to refuse to prescribe drugs for enhancement:
- They have reason to believe that the harm exceeds the benefit for a particular patient. Such a reason would trump respect for patient autonomy, although doctors owe it to the patients to explain their reasons.
- They have concerns about distributive justice, because neuroenhancement therapies will likely be available only to those who can afford to pay out of pocket. “Whether such an inequality of distribution will provide a sufficient basis to prohibit the use of neuroenhancement at all is an issue that will have to be addressed by the medical profession and society,” the guidelines state. “For the time being, neurologists may wish to consider the effects such limited access may have on society when deciding whether to provide enhancements to patients who request them.”
The guidelines may come as a surprise to people who are still puzzling out the ethical arguments for and against “Botox for the brain,” including the unanswered questions about safety. Isn’t it putting the cart before the horse to lay out an ethical framework for prescribing cognitive enhancers before we have agreed whether it is even ethical to use them?
The neurology association statement recognizes that question and then dispenses with it by saying that cognitive enhancers are likely to be considered ethically permissible by society and by the profession for two reasons. One is that they will come to be regarded as akin to cosmetic surgery for improving well-being. The other is that evidence is likely to show that their benefits outweigh their risks.
Erik Parens, senior research scholar at The Hastings Center who studies enhancement issues, disagrees that widespread acceptance of and benefit from cognitive enhancers are a given. But whether society will wait to find out is another matter. Upon reading the guidelines, Parens said, “The hurricane seems ready to make land.”