Op-Ed by Anjan Chatterjee, MD, August 2004
Understand how neuropharmcologic agents may challenge our notions
of medicine's role.
Basic neuroscience and neuropharmacology are beginning to yield
therapies for cognitive disorders. While we can eagerly anticipate
treatments for dementing illnesses, stroke, traumatic brain injury,
and developmental abnormalities, these very treatments raise uncomfortable
questions. If we can improve cognitive systems in disease, can
we also do so in health? Should we practice cosmetic neurology?
The possibility of “better brains” has captured the
imagination of the press, policy pundits, and ethicists [1-10].
With few exceptions, physicians have not contributed to these
discussions, despite their central role in this unfolding drama
[11,12].
Cosmetic neurology includes the use of botulinum toxin to brush
away wrinkles. However, it also alters how we function and feel,
rather than just how we look. Many interventions to improve cognitive
and emotional systems are available now, and others are on the
horizon. The risks and benefits of newer medications remain to
be worked out. However, we can assume that some version of these
medications will be relatively efficacious and safe. The accompanying
article on neuroethics by Martha Farah reviews the anticipated
pharmacopeia of cosmetic neurology and the deep ethical concerns
raised for individuals and society (also see [12]). The focus
here is on the role of the physician in managing the use of cosmetic
neurologic interventions.
Framing the Issue: the Purpose of Medicine
Ethical discussions of cosmetic neurology often frame the issue
as one of therapy versus enhancement [6, 13]. Therapy treats disease
and enhancement improves normal abilities. Most people consider
therapy desirable. By contrast, many pause at enhancement. Francis
Fukayama, for example, opines, “the original purpose of
medicine is to heal the sick, not turn healthy people into gods”
[14]. He suggests that public policy should restrict research
for enhancement.
For 2 reasons, the distinction between therapy and enhancement
is less useful than one might hope. First, notions of disease
often lack clear boundaries. For example, if individuals of short
stature can be “treated” with growth hormone [15],
does it matter whether they are short because of a growth hormone
deficiency or because of other reasons [13]? Second, promoting
research for therapy and restricting it for enhancement ignores
the simple fact that research in one often applies to the other.
The therapy versus enhancement distinction also obscures what
for physicians may be the critical question: What is the purpose
of medicine? The strength of allopathic medicine has been its
scrutiny of disease mechanisms. Understanding the biology of malfunction
provides insight into how to fix that malfunction. Despite its
undoubted successes, this approach has limits. Most notably, the
quality of patients' lives does not always correspond well to
biomarkers and symptoms of disease. The symptoms of Parkinson's
disease that are most responsive to dopamine agonists are not
those that bother patients most [16]. Measures of disease activity
may not be the best indicator of the impact of multiple sclerosis
on patients [17]. Recognizing the limits of clinical and pathological
indices, assessing patients' quality of life is now a routine
practice in therapeutic trials. Such assessments seem eminently
reasonable. After all, the point of treating a disease is to improve
patients' quality of life. However, if a purpose of medicine is
to improve quality of life for people who happen to be sick, then
why not apply medical knowledge to improve the quality of life
of those who happen to be healthy?
Inevitability
Cosmetic neurology raises several serious ethical concerns. These
interventions challenge fundamental notions of character and individuality;
it is likely that they will be used coercively, and cosmetic neurology
will not lessen the burden of distributive justice in a country
in which the quality of health care is polarized by economic class.
It is improbable, however, that cosmetic neurology will be restrained
significantly by journalistic consternation, religious admonition,
and government regulation. More likely, such restraints will be
overwhelmed by free markets and military innovations.
The market. Pharmaceutical companies stand to make substantial
profits and will probably support social pressures that encourage
wide use of cosmetic neurology. According to Carl Elliott, in
2001 GlaxoSmithKline spent $91 million dollars in direct advertising
to consumers for its medication Paxil [8], more than Nike spends
on its top shoes. Advertisements for better brains would undoubtedly
prey on an insecure public. Gingko Biloba, despite underwhelming
effects on cognition [18], is a billion dollar industry. Pharmaceutical
companies are not oblivious to the marketing possibilities of
new “interventions” that could apply to the entire
population [19, 20]. Sadly, the academy is unlikely to restrain
Industry. Scientific leaders who discover new therapeutic possibilities
are quick to stake biotech claims [20]. Joint ventures between
universities and pharmaceutical companies are increasingly common.
The military. Imagine a soldier who is stronger, faster, more
enduring, learns more quickly, needs less sleep, and is not hampered
by disturbing combat memories. The military's deep interests in
cognitive enhancements date back to “go-pills” (amphetamines)
for World War II soldiers [20], and continue to the present [20,
21]. For example, military investigators found that modafinil
[a wakefulness-promoting agent] has its greatest effects in helicopter
simulation performances at the combined nadir of sleep deprivation
and circadian troughs [22]. Relevant findings from military research
are likely to trickle down to civilians. Over-fed Hummer vehicles
maneuver through the cobbled streets of Philadelphia. Perhaps
Hummer brains are around the corner.
The Role of Physicians
Americans believe that the pursuit of happiness is an inalienable
right. This pursuit assumes we know what constitutes happiness
[23]. Fame and fortune have been standard proxies for happiness
in American culture. Better brains may very well join the list,
either as a means to fame and fortune or as a direct source of
happiness [24].
Scientific, economic, marketing, and regulatory forces are likely
to shape the role physicians will play. The details are difficult
to predict, but what is certain is that physicians will engage
in cosmetic neurology. This practice will be complicated by the
fact that physicians will not be able to rely on the conventions
of traditional practice. Neurologists may have special understanding
of the potential risks and benefits of quality of life interventions
that work through the nervous system, but they have no special
insight into the underpinnings of happiness.
One plausible scenario is that physicians will become quality-of-life
consultants. Physicians might offer a menu of options, with the
likely outcomes and the incumbent risks stated in generalities.
The role would be to provide information while abrogating final
responsibility for decisions to patients. Abrogation of such responsibility
is promoted by current practice norms. Financial incentives in
medicine are now driven by paper trails and diagnostic studies,
rather than by personal engagement with patients. A comfortable
stance would be to let people decide for themselves. After all,
isn't autonomy what patients want?
It turns out that the degree of autonomy patients want is not
so clear, especially when they are sick (as reviewed in [25]).
Furthermore, the bewildering array of choices available to American
consumers in almost every domain of life is a source of considerable
anxiety [26 ]. A practice of medicine that encourages patients
to be consumers is in danger of compounding these anxieties. I
am not advocating that physicians become disengaged purveyors
of quality-of-life elixirs. I am suggesting that this role is
a distinct possibility given current trajectories of medical practice.
In a litigious society, many physicians would gladly shed the
irksome traditional mantle of beneficence.
Where do you stand?
Since 1997, the FDA has permitted direct marketing to consumers.
Physicians can anticipate facing questions from “patients”
and advocacy groups in which distilling principle from prejudice
is not easy. To make these issues concrete, I invite readers to
consider the following questions.
1. Would you take a medication with minimal side-effects half
an hour before Italian lessons if it allowed you to learn the
language more quickly?
2. Would you give your children a medication with minimal side-effects
half an hour before piano lessons if it allowed them to learn
better?
3. Would you pay more for flights whose pilots were taking a
medication that made them react better in emergencies?
4. Would you want residents to take medications after call nights
that would make them less likely to make mistakes in caring for
patients because of sleep-deprivation?
5. Would you take a medicine that selectively dampened disturbing
memories?
References
1. Groopman J. Eyes wide open. The New Yorker. December 3, 2001.
52-57.
2. Marcus S. Neuroethics: Mapping the Field. New York: Dana Press;
2002.
3. Rose S. Smart drugs: do they work, will they be legal? Nature
Reviews Neuroscience. 2002;3:975-979.
4. The ethics of brain science: open your mind. The Economist.
May 25, 2002; 77-79.
5. Farah MJ. Emerging ethical issues in neuroscience. Nature Neuroscience.
2002;5:1123-1129.
6. Wolpe P. Treatment, enhancement, and the ethics of neurotherapeutics.
Brain and Cognition. 2002;50:387-305.
7. Plotz D. The ethics of enhancement. Slate. March 12, 2003.
Accessed July 27, 2004.
8. Elliot C. American bioscience meets the American dream. The
American Prospect. 2003;14:38-42.
9. President's Council on Bioethics. Beyond
Therapy: Biotechnology and the Pursuit of Happiness. Washington,
DC; President's Council on Bioethics. 2003. Accessed July 27,
2004.
10. Baily R. The
battle for your brain. Reasononline. February 2003. Accessed
July 26, 2004.
11. Whitehouse P, Juengst E, Mehlman M, Murray T. Enhancing cognition
in the intellectually intact. Hastings Center Report. 1997;27
(May-June):14-22.
12. Chatterjee A. Cosmetic neurology: the controversy over enhancing
movement, mentation and mood. Neurology. 2004 (in press).
13. Daniels N. Normal functioning and the treatment-enhancement
distinction. Cambridge Quart Healthcare Ethics. 2000;9:309-322.
14. Fukayama F. Our Posthuman Future. New York: Farrar, Straus
& Giroux, 2002.
15. Cuttler L, Silvers J, Singh J, et al. Short stature and growth
hormone therapy: a national study of physician recommendation
patterns. JAMA. 1996;276: 531-537.
16. Harris Interactive. Inc. The
impact of Parkinson's disease on quality of life. Online Survey.
2003.
17. Nortvedt M, Riise T. The use of quality of life measures in
multiple sclerosis research. Multiple Sclerosis. 2003;9:63-72.
18. Solomon P, Adams F, Silver A, Zimmer J, DeVeaux R. Ginkgo
for memory enhancement: a randomized controlled trial. JAMA. 2002;288:835-840.
19. Langreth R. Viagra for the brain. Forbes. February 4, 2002:
46-52.
20. Hall S. The quest for a smart pill. Scientific American. 2003;289:54-65.
21. George M. Stimulating the brain. Scientific American. 2003;289:67-77.
22. Caldwell JJ, Caldwell J, Smythe NR, Hall K. A double-blind,
placebo-controlled investigation of the efficacy of modafinil
for sustaining the alertness and performance of aviators: a helicopter
simulator study. Psychopharmacology. 2000;150:272-282.
23. Elliot C. Better than Well: American Medicine Meets the American
Dream. New York: WW Norton & Company; 2003.
24. Kass L. The pursuit of biohappiness. Washington Post. October
16, 2003: A25.
25. Schneider C. The Practice of Autonomy: Patients, Doctors and
Medical Decisions. New York: Oxford Press; 1998.
26. Schwartz B. The Paradox of Choice: Why Less Is More. New York:
Ecco, 2004.
Anjan Chatterjee, MD, is associate professor in the Department
of Neurology and a faculty member of the Center for Cognitive
Neuroscience at the University of Pennsylvania, Philadelphia,
Pa.
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