What is the difference between a plastic surgeon and a neurologist? No, that’s not the start to some esoteric medical joke—it’s a central issue in one of the first reports to offer brain doctors practical advice on how to deal with healthy patients who ask for neuroenhancing drugs.
The answer, according to the Sept. 23 Neurology article, is that sometimes there isn’t much difference at all. Just as plastic surgeons can provide cosmetic treatments for patients, neurologists are well within their rights to prescribe—or not—stimulants to help patients improve test performance or memory enhancers to stave off normal declines in recall. These treatments, increasingly being sought by busy students and aging workers, are ethically and legally permissible, the authors argue, falling between the “ethically obligatory” treatments that are at the core of medical practice and harmful practices that are outright disallowed.
“Neuroenhancement and cosmetic surgery have a lot in common,” says lead author Dan Larriviere, an assistant professor of neurology at the University of Virginia, because off-label use of drugs—that is, employing them for conditions other than those originally tested against—is left up to the discretion of medical providers. “Both [specialties] don’t correct. Both are permissible but not obligatory.”
That’s not to say that neurologists should be giving out neuroenhancing drugs to everyone who asks for them. The first thing doctors must do is ensure “that a patient who requests a neuroenhancer should be treated like a patient,” says Larriviere, who has both a medical and law background. Doctors should take an extensive history and conduct a thorough examination to make sure no underlying condition is prompting the request, he says.
Assuming the patient is indeed alright, a number of additional factors come into play. For instance, a doctor’s primary duty continues to be to ensure that treatment will actually help and not harm the person. In the case of neuroenhancers, that will inevitably require a judgment call, as the drugs’ long-term effects on “normals” have not been studied extensively.
For instance, preliminary data suggests the benefits do not apply equally to everyone or to every mental skill, that the drugs may have only minor effects in healthy people and that they may cause declines instead of improvements in some cases. These complexities, as well as concerns that a patient’s future ability to make medical decisions could become compromised, are legitimate reasons for denying a request, according to the paper. Fears of malpractice suits are another concern—“we just don’t know what kind of analysis courts would engage in if a patient was harmed in these cases,” Larriviere says.
But for a doctor who thinks it’s worth it, there are no universal proscriptions against writing the prescription, as long as the doctor has made the patient aware of the potential consequences, set clear guidelines about when to stop treatment and followed other ethical mandates.
Because these drugs are expensive, some people worry that allowing doctors to prescribe them to healthy people would exacerbate social and economic inequalities. Others foresee patients who get an unwanted answer “doctor-hopping” until they find someone who will prescribe them their drug of choice. But those are issues to be taken up at a societal or government level and should not affect individual medical decision, Larriviere says.
Larriviere acknowledges that the report is likely to be controversial. Even though people have been taking some mild neuroenhancers—such as caffeine—for centuries, the potency of modern versions makes numerous people, including many in the medical community, uncomfortable about their “unnecessary” use. Yet surveys and anecdotal reports suggest that it is becoming commonplace in some schools and workplaces, and doctors have had little practical guidance on how to respond to requests until now.
Whatever their ultimate thoughts on the issue, Larriviere says, many doctors have said they appreciate the new paper, because it both spells out the legal and ethical rules governing the issue and provides specific types of reasoning that doctors can use to justify a decision. “The articles about this have largely been philosophical and ethical pieces,” he says. “They didn’t offer any practical guidance to the physician.”
—Aalok Mehta
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