American Academy of Neurology practice bulletin regarding prescription of "neuroenhancement" in well adults

practice of medicine traditional goals or obligations

1. prevent and diagnose disease or injury

2. cure/treat the disease or injury

3. reduce suffering

4. educate

5. help patients die in peace and dignity

6. reassure the well

ethically more complicated behaviors

1. participating in executions

2. participating in interrogations

i add these

3. use of medicine as a direct coercive force

4. research and experimentation with complicated ethical questions

5. profit motivated medicine

role is divided into

core domain

-these are obligatory

secondary domain

-considered ethically permissible

AAN describes prescribing medication for the purpose of neuroenhancement at best to fall into the category of secondary domain and at worst ethically impermissible

reasons prescribing for enhancement may be considered permissible

-improves well being (similarly to plastic surgery)

-benefits > risks

issues worth considering before prescribing-

-prescriptions will be "off-label" until medications are specifically designed and approved for the purpose of enhancement

-"off label" use should be based on

1. plausible rationale

2. based on available evidence

3. consistent w/standard of care (unfortunately very little clinical evidence to inform this use)

-before prescribing must inform patient

1. not FDA approved for this use

2. side effects

3. risks (short term and long term)

4. alternatives to not taking the medication

Ethical considerations before prescribing

-Thorough assessment of patient

e.g. - just because a patient is requesting neuroenhancement does not mean they are well, have to do a full work up for existing pathology. the request itself may be evidence of existing condition or the patient's interpretation of their symptoms

thus the request for neuroenhancement is still a "chief complaint"

-Beneficence and nonmaleficence

the putative benefits of enhancement (increased competitiveness, intelligence etc) are difficult to quantify and thus difficult to compare to the risks of treatment. thus clearly stating treatment goals will help the physician

-Distributive justice

drugs unlikely to be covered by third party payers, will remain in the domain of the rich, so consider the effects of limited access on society.

-conflict of interest

"avoid financial arrangements that influence patient care", inform patients of conflict of interest (stock, financial incentives etc...)

-Liability

courts will probably analyze injury claims for neuroenhancement similarly as they do other cosmetic procedures - courts may or may not be more aggressive

case: Zalazar v Vercimack - expert witness testimony is not needed to prove causation for cases involving informed consent elective medical procedures because "there is no medical issue that requires explanation for the jury".

refrain from guaranteeing an outcome

The following are a couple of selected key practice guidelines put forth by the AAN

1. prescriptions of meds for "neuroenhancement" are not legally obligatory, not prohibited and legally permissible in the US

2. prescriptions of meds for "neuroenhancment" are not ethically obligatory or prohibited and therefore are permissible

3. there is limited evidence of efficacy and safety info for these agents

4. liability is uncertain and may favor the plaintiff

5. refusal to prescribe is both ethically and legally permissible

6. informed consent applies for the prescription of "neuroenhancing" meds

7. ending prescriptions for "neuroenhancement" after they have been initiated is both legally and ethically permissible

Reference:

Larriviere D, Williams M, Rizzo M, Bonnie R. "Responding to requests from adult patients for neuroenhancments, Guidance of the Ethics, Law and Humanities Committee" 2009. American Academy of Neurology. www.neurology.org