Staff from the neuroethics unit at McGill University in Montréal, Quebec, published an article in CMAJ titled, “Should physicians prescribe cognitive enhancers to healthy individuals?”1 During my career, I have had a number of contacts with ethicists. I am skeptical when ethicists, without having any clinical experience in the practice of medicine, give advice to practising physicians on how to behave.
Stimulant medication does produce substantial cognitive enhancement in healthy individuals. Particularly in university populations, diverting cognitive enhancers (which are prescribed for attention-deficit/hyperactivity disorder) to individuals who want to use neurostimulants for cognitive enhancement particularly around exam time is a major issue.
My position is that if individuals are going to use cognitive enhancers then they should do so under the direct care of a physician, rather than simply getting these medications from friends or via the Internet, where they are readily available. Certain people should never use cognitive enhancers, and only careful screening by physicians will identify such people.
The authors state that cognitive enhancers, if they were available, would be available only to a limited segment of the population because of financial reasons and therefore prescribing them would imply a breach of ethical principles. I find this position to be untenable. Individuals in Canada are free to purchase all manner of services including private education and private health care, and most people must pay for prescribed medication because of limited public coverage. Large sums of money are spent on cosmetic surgery without any concerns about distributive justice or deployment of physicians. To suggest that neurocognitive medications should not be available because everyone could not afford them is preposterous.
William Safire has defined neuroethics as “The examination of what is right and wrong and good and bad about the treatment of, perfection of, or unwelcome invasion of and worrisome manipulation of the human brain.”2 There are a number of ethical principles that need to be addressed. Forlini and colleagues1 look at only one, distributive justice. I prefer a more liberal position when it comes to ethical issues, specifically that everyone should be free to do what they want as long as their actions do not cause harm to others. I specifically reject the principle that physicians have a role in ensuring that medical services are equally distributed.
I remain ambivalent in my own practice about prescribing neurostimulant medications for enhancement in the absence of psychiatric illness. I believe it would be unethical to prescribe cognitive enhancers to children and teenagers for these purposes, although I have been pressured on a number of occasions to do so by parents who want their children to be scoring even higher academically than they are currently.
If the profession is to have an ethical position on this matter, I would welcome leadership by the Canadian Medical Association or the Canadian Psychiatric Association that would involve input primarily from practising physicians.