To heal, or to enhance? Medicine grapples with "cosmetic neurology"

Lecturing a group of students last fall, Martha J. Farah, PhD, commented that there was probably someone in the audience making use of modafinil, approved to treat narcolepsy but mostly prescribed off-label to long-haul truckers, jet-lagged ocean hoppers and anyone else too busy to sleep.

"You were right about that!" said a graduate student who approached Dr. Farah, director of the University of Pennsylvania's Center for Cognitive Neuroscience, after the talk. Once a week, said the student, who is also a teaching assistant, he would find himself falling behind on answering e-mail and grading work. With modafinil, he could stay up all night and still work through the next day.

Dr. Farah's observation was far from a shot in the dark. Increasingly, students at highly competitive universities such as Penn are using modafinil, or stimulants intended to treat attention-deficit/hyperactivity disorder, to enhance their already considerable abilities. Some students are asking doctors for these so-called smart pills, though most obtain them illegally from campus dealers.

College kids aren't alone in looking to doctors to do more than just cure their ills. Middle-aged men ask physicians for testosterone boosters. Some adults even seek growth hormones, one of the engines that allegedly helped Barry Bonds overtake Babe Ruth on baseball's all-time home run list.

But should doctors say yes when patients ask for enhancement instead of healing?

It's a question that medicine has grappled with on a smaller scale for years. Cosmetic surgery posed similar questions decades ago and continues to outpace medically necessary reconstructive surgeries. Peter Kramer's 1993 book, Listening to Prozac, alerted the nation to patients who sought to feel "better than well." And it didn't take long after Viagra's 1998 approval before some normally functioning men began using the drug to enhance their sexual experiences.

The question of whether to abide patient requests for enhancement treatments will only continue to intensify as new drugs hit the market. For example, Alzheimer's medication that is in the pipeline could potentially enhance healthy individuals' memory.

In fact, the potential for genetic enhancement is so great that the National Institutes of Health is funding an investigation of the ethical implications of the research. The AMA's Council on Ethical and Judicial Affairs also is studying human enhancement and may issue ethical guidelines for physicians.

Defining medicine

Enhancement has not traditionally been a goal of medicine due to the ethical principle of non-maleficence, aka "first, do no harm," said Maurice Bernstein, MD. Transforming physicians from healers to enhancers has the potential to "degrade" this principle, said Dr. Bernstein, an associate clinical professor of medicine at the University of Southern California's Keck School of Medicine who recently wrote about the issue at his Bioethics Discussion blog bioethicsdiscussion.blogspot.com/.

"I don't believe that society should add this new role to the practice of medicine," Dr. Bernstein said via e-mail, because "the motivation for action is not related to disease but to aesthetics and personal quality-of-life issues, independent of any pathology."

Howard Brody, MD, PhD, a family physician and Michigan State University bioethicist, agrees. In an American Journal of Bioethics article he co-authored last year, he argued that one of a physician's ethical duties is to avoid "disproportionate risks of harm that are not balanced by the prospect of compensating medical benefits." Enhancement interventions, he wrote, challenge the integrity of the medical profession.

But Ronald Bailey, author of Liberation Biology: The Scientific and Moral Case for the Biotech Revolution and an enhancement supporter, said a redefinition of what doctors "treat" may be in order. "What does disease mean? It means 'dis-ease' -- you're not happy, you're uncomfortable," he said. "Why not apply that to aging? Why not apply that to the fact that my nose isn't pointy enough? ... If patients are unsatisfied with some aspect of their lives and doctors can help them with very few risks, then why shouldn't they do so?"

Some say a transformation of the physician's role is likely. A colleague of Dr. Farah's, Anjan Chatterjee, MD, associate professor of neurology at Penn, has dubbed the enhancement use of drugs such as modafinil, methylphenidate and dextroamphetamine "cosmetic neurology." After his 2004 paper on the topic was published, some physicians told him they were being pressured to prescribe the drugs for enhancement purposes.

Dr. Chatterjee expects medical economics will drive some physicians to embrace the enhancement role with open arms, especially if it means regaining some of the autonomy lost to managed care plans. In the field of plastic surgery, he explained, the shift occurred over 80 years. Plastic surgery was born in response to the needs of soldiers injured in World War I. By 2004, Dr. Chatterjee said, cosmetic surgeries outnumbered reconstructive surgeries two to one.

How could cognitive and other enhancements become medicalized?

"The way it could get redefined is if physicians start seeing themselves as having a duty to contribute to their patients' quality of life," said Dr. Chatterjee. Recent emphasis on quality-of-life measures in clinical trials, for example, has sensitized physicians to the issue and might become a "slippery slope" that "could undermine this convenient distinction between treatment and enhancement." Dr. Chatterjee said he sees pros and cons to enhancement and has not settled his view on the issue.

Blurring the lines

It can be a fuzzy distinction, said William P. Cheshire Jr., MD, associate professor of neurology at the Jacksonville, Fla., Mayo Clinic.

"Consider the hypothetical case of an adolescent with ADHD who requests a dose increase of her stimulant in order to gain an academic edge," Dr. Cheshire said via e-mail. "The line between achieving normal and enhanced mental focus begins to blur.

"It is more difficult to justify a medical intervention and its associated risks for the purpose of enhancing normal function than for the purpose of restoring impaired function," Dr. Cheshire added. "Nevertheless, the ethical distinction between therapy and enhancement in many cases may be difficult to define."

Politicians and regulators may take these difficult decisions out of the hands of physicians and patients, which Dr. Cheshire said would be suboptimal.

"I'd prefer to see a solution where physicians are educated enough to be able to sit down and have a reasonable conversation with their patients without being forced by regulators to have the decision made for them," he said.

Richard M. Restak, MD, clinical professor of neurology at The George Washington University School of Medicine and Health Sciences and author of The Naked Brain: How the Emerging Neurosociety is Changing How We Live, Work and Love, said regulatory fears have affected his clinical decisions about enhancement interventions.

"I am asked as a physician about cognitive enhancers, and I don't prescribe them," Dr. Restak said. "Such use is definitely off-label and puts the physician at a disadvantage should something go wrong."

In the case of growth hormone, the consequences for physicians could be harsh. Congress has restricted legal use of the drug to only approved nonenhancement uses, such as the treatment of dwarfism, growth hormone deficiency or AIDS- and cancer-related wasting. Unlike other drugs, off-label prescribing is illegal and potentially prosecutable as a felony, said Maxwell Mehlman, a professor of law and bioethics at Case Western Reserve University in Cleveland.

The Food and Drug Administration has issued warning letters to manufacturers of growth hormone who have marketed its unapproved uses, though Mehlman said he's unaware of any physicians being prosecuted.

For now, individual physicians will have to decide, with patients, how far they are willing to go along the treatment-enhancement continuum.

"I know physicians on both sides of this issue," the Mayo Clinic's Dr. Cheshire said. "I know some who say we should really do whatever patients find helpful and others who are against any form of enhancement in medicine. ... There are questions in the middle that are hard to answer."