Neuroethics

, Volume 2, Issue 2, pp 89–102

Ethically Justified, Clinically Applicable Criteria for Physician Decision-Making in Psychopharmacological Enhancement

Original Paper

Abstract

Advances in psychopharmacology raise the prospects of enhancing neurocognitive functions of humans by improving attention, memory, or mood. While general ethical reflections on psychopharmacological enhancement have been increasingly published in the last years, ethical criteria characterizing physicians’ role in neurocognitive enhancement and guiding their decision-making still remain highly unclear. Here it will be argued that also in the medical domain the use of cognition-enhancing drugs is not intrinsically unethical and that, in fact, physicians should assume an important role in gating their usage. For finding normative orientation, concepts of disease, normality or medicine will not be helpful since—due to their cryptonormative nature—they rather hamper than allow targeted discussion and decision-making. As an alternative, the common and widely accepted bioethical criteria of beneficence, non-maleficence, autonomy and distributive justice allow a clinically applicable, highly differentiated context- and case-sensitive approach. By embedding decision-making in a participative physician–patient relationship extrinsic objections against neurocognitive enhancement (e.g. invalid perceptions about efficacy, benefit or risk; questionable voluntariness; restrained decision-making capacity) can be curtailed.

Keywords

Neuroenhancement Psychopharmacology Ethics Physician Drugs 

References

  1. 1.
    Elliott, C. 2003. Better than well: American medicine meets the American dream. New York: Norton.Google Scholar
  2. 2.
    Farah, M.J., J. Illes, R. Cook-Deegan, H. Gardner, et al. 2004. Neurocognitive enhancement: what can we do and what should we do? Nature Reviews Neuroscience 5: 421–425.CrossRefGoogle Scholar
  3. 3.
    Sullivan, M. 2003. The new subjective medicine: taking the patient’s point of view on health care and health. Social Science & Medicine 56: 1595–1604.CrossRefGoogle Scholar
  4. 4.
    Synofzik, M. 2005. Measuring the unmeasurable? Quality of life and medical decision making. Virtual Mentor. Ethics Journal of the AMA 7. http://virtualmentor.ama-assn.org/2005/02/pdf/fred1-0502.pdf. Accessed 12/05/08.
  5. 5.
    Whitehouse, P., E. Juengst, M. Mehlman, and T. Murray. 1997. Enhancing cognition in the intellectually intact. Hastings Center Report 27: 14–22.Google Scholar
  6. 6.
    Parens, E. (Ed.), 1998. Enhancing human traits. Ethical and social implications. Washington: Georgetown University Press.Google Scholar
  7. 7.
    Mehlman, M.J. 2004. Cognition-enhancing drugs. Milbank Quarterly 82: 483–506.CrossRefGoogle Scholar
  8. 8.
    Chatterjee, A. 2004. Cosmetic neurology: the controversy over enhancing movement, mentation, and mood. Neurology 63: 968–974.Google Scholar
  9. 9.
    Sahakian, B., and S. Morein-Zamir. 2007. Professor’s little helper. Nature 450: 1157–1159.CrossRefGoogle Scholar
  10. 10.
    Juengst, E.T. 1998. What does enhancement mean? In Enhancing human traits. Ethical and social implications, ed. E. Parens, 29–47. Washington: Georgetown University Press.Google Scholar
  11. 11.
    Synofzik, M. 2008. Psychopharmakologisches Enhancement: Ethische Kriterien jenseits der Treatment-Enhancement-Unterscheidung. In Neuro-Enhancement. Ethik vor neuen Herausforderungen, eds. D. Talbot, B. Schöne-Seifert, J. Ach, and U. Opolka. Paderborn: Mentis.Google Scholar
  12. 12.
    Fukuyama, F. 2002. Our posthuman future. New York: Farrar, Straus & Giroux.Google Scholar
  13. 13.
    Sandel, M.J. 2007. The case against perfection: Ethics in the age of genetic engineering. Cambridge: Harvard University Press.Google Scholar
  14. 14.
    Synofzik, M. 2006. [Effective, indicated—and yet without benefit? The goals of dementia drug treatment and the well-being of the patient.]. Zeitschrift fūr Gerontologie und Geriatrie 39: 301–307.CrossRefGoogle Scholar
  15. 15.
    Wiesing, U. 1998. Kann die Medizin als praktische Wissenschaft auf eine allgemeine Definition von Krankheit verzichten. Zeitschrift für Medizinische Ethik 44: 83–97.Google Scholar
  16. 16.
    Hesslow, G. 1993. Do we need a concept of disease. Theoretical Medicine 14: 1–14.CrossRefGoogle Scholar
  17. 17.
    Boorse, C. 1977. Health as a theoretical concept. Philosophy of Science 44: 542–573.CrossRefGoogle Scholar
  18. 18.
    Lenk, C. 2008. Veränderung kognitiver Merkmale und das Argument der “Offenheit des Lebensweges”. In Neuro-Enhancement. Ethik vor neuen Herausforderungen, eds. D. Talbot, B. Schöne-Seifert, J. Ach, and U. Opolka. Paderborn: Mentis.Google Scholar
  19. 19.
    Daniels, N. 1985. Just health care. Cambridge, MA: CUP.Google Scholar
  20. 20.
    Sabin, J.E., and N. Daniels. 1994. Determining “medical necessity” in mental health practice. Hastings Center Report 24: 5–13.Google Scholar
  21. 21.
    Daniels, N. 2000. Normal functioning and the treatment-enhancement distinction. Cambridge Quarterly of Healthcare Ethics 9: 309–322.CrossRefGoogle Scholar
  22. 22.
    Petersen, R.C., G.E. Smith, S.C. Waring, R.J. Ivnik, et al. 1999. Mild cognitive impairment: clinical characterization and outcome. Archives of Neurology 56: 303–308.CrossRefGoogle Scholar
  23. 23.
    Moynihan, R., I. Heath, and D. Henry. 2002. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 324: 886–891.CrossRefGoogle Scholar
  24. 24.
    Moynihan, R., and D. Henry. 2006. The fight against disease mongering: generating knowledge for action. PLoS Medicine 3: e191.CrossRefGoogle Scholar
  25. 25.
    Moynihan, R., E. Doran, and D. Henry. 2008. Disease mongering is now part of the global health debate. PLoS Medicine 5: e106.CrossRefGoogle Scholar
  26. 26.
    Neuroinvestment. Cortex Comments. 2005. http://www.neuroinvestment.com/CORXcom.html. Accessed 16 May 2008.
  27. 27.
    Parens, E. 2005. Creativity, gratitude, and the enhancement debate. In Neuroethics. Defining the issues in theory, practice and policy, ed. J. Illes, 75–86. Oxford: OUP.Google Scholar
  28. 28.
    Hanson, M.J., and D. Callahan. (Eds.), 1999. The goals of medicine: The forgotten issues in health care reform. Washington, DC: Georgetown University Press.Google Scholar
  29. 29.
    Schermer, M., I. Bolt, R. De Jongh, and B. Olivier. 2009. Psychopharmaceutical enhancers: enhancing identity? Neuroethics. doi:10.1007/s12152-008-9031-7.
  30. 30.
    Schöne-Seifert, B., Ach, J., Opolka, U., Talbot, D. (Eds.), 2008. Neuroenhancement- Ethik vor neuen Herausforderungen, Mentis, Paderborn.Google Scholar
  31. 31.
    Beauchamp, T., and J. Childress. 2008. Principles of biomedical ethics. Oxford: Oxford University Press.Google Scholar
  32. 32.
    Butcher, J. 2003. Cognitive enhancement raises ethical concerns. Academics urge pre-emptive debate on neurotechnologies. Lancet 362: 132–133.CrossRefGoogle Scholar
  33. 33.
    Harris, J., and M. Quigley. 2008. Humans have always tried to improve their condition. Nature 451: 521.CrossRefGoogle Scholar
  34. 34.
    de Jongh, R., I. Bolt, M. Schermer, and B. Olivier. 2008. Botox for the brain: enhancement of cognition, mood and pro-social behavior and blunting of unwanted memories. Neuroscience and Biobehavioral Reviews 32: 760–776.CrossRefGoogle Scholar
  35. 35.
    Szegedi, A., R. Kohnen, A. Dienel, and M. Kieser. 2005. Acute treatment of moderate to severe depression with hypericum extract WS 5570 (St John’s wort): randomised controlled double blind non-inferiority trial versus paroxetine. BMJ 330: 503.CrossRefGoogle Scholar
  36. 36.
    Moncrieff, J., S. Wessely, R., and Hardy. 2004. Active placebos versus antidepressants for depression. Cochrane Database of Systematic Reviews CD003012.Google Scholar
  37. 37.
    Blumenthal, J.A., M.A. Babyak, K.A. Moore, W.E. Craighead, et al. 1999. Effects of exercise training on older patients with major depression. Archives of Internal Medicine 159: 2349–2356.CrossRefGoogle Scholar
  38. 38.
    Wesensten, N.J., G. Belenky, M.A. Kautz, D.R. Thorne, et al. 2002. Maintaining alertness and performance during sleep deprivation: modafinil versus caffeine. Psychopharmacology (Berl) 159: 238–247.CrossRefGoogle Scholar
  39. 39.
    Kaduszkiewicz, H., T. Zimmermann, H.P. Beck-Bornholdt, and H. van den Bussche. 2005. Cholinesterase inhibitors for patients with Alzheimer’s disease: systematic review of randomised clinical trials. Bmj 331: 321–323.CrossRefGoogle Scholar
  40. 40.
    Lacasse, J.R., and J. Leo. 2005. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Medicine 2: e392.CrossRefGoogle Scholar
  41. 41.
    Bostrom, N. 2008. Drugs can be used to treat more than disease. Nature 451: 520.CrossRefGoogle Scholar
  42. 42.
    Kirsch, I., B.J. Deacon, T.B. Huedo-Medina, A. Scoboria, et al. 2008. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine 5: e45.CrossRefGoogle Scholar
  43. 43.
    Birks, J., and L. Flicker. 2006. Donepezil for mild cognitive impairment. Cochrane Database of Systematic Reviews 3: CD006104.Google Scholar
  44. 44.
    Synofzik, M., Marckmann, G. in press. Dein Wille geschehe? Die Pluralität evaluativer Vorstellungen eines gelingenden Lebens und die Fürsorgepflichten des Arztes., In S Michels, T Potthast, U Wiesing. eds. Pluralität in der Medizin.Google Scholar
  45. 45.
    Trindade, E., D. Menon, L.A. Topfer, and C. Coloma. 1998. Adverse effects associated with selective serotonin reuptake inhibitors and tricyclic antidepressants: a meta-analysis. Cmaj 159: 1245–1252.Google Scholar
  46. 46.
    Swanson, J.M., G.R. Elliott, L.L. Greenhill, T. Wigal, et al. 2007. Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. Journal of the American Academy of Child and Adolescent Psychiatry 46: 1015–1027.CrossRefGoogle Scholar
  47. 47.
    El-Zein, R.A., S.Z. Abdel-Rahman, M.J. Hay, M.S. Lopez, et al. 2005. Cytogenetic effects in children treated with methylphenidate. Cancer Letter 230: 284–291.CrossRefGoogle Scholar
  48. 48.
    Volkow, N.D., and J.M. Swanson. 2008. The action of enhancers can lead to addiction. Nature 451: 520.CrossRefGoogle Scholar
  49. 49.
    Ansorge, M.S., M. Zhou, A. Lira, R. Hen, and J.A. Gingrich. 2004. Early-life blockade of the 5-HT transporter alters emotional behavior in adult mice. Science 306: 879–881.CrossRefGoogle Scholar
  50. 50.
    Whittington, C.J., T. Kendall, P. Fonagy, D. Cottrell, et al. 2004. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet 363: 1341–1345.CrossRefGoogle Scholar
  51. 51.
    Finucane, T.E., and J.R. Gilstad. 2006. Should cholinesterase inhibitors be used to treat Alzheimer's disease. Nature Clinical Practice Neurology 2: 118–119.CrossRefGoogle Scholar
  52. 52.
    Synofzik, M. 2006. Kognition a la carte? Der Wunsch nach kognitionsverbessernden Psychopharmaka in der Medizin. Zeitschrift für Ethik in der Medizin 18: 37–50.CrossRefGoogle Scholar
  53. 53.
    DeGrazia, D. 1991. The ethical justification for minimal paternalism in the use of the predictive test for Huntington’s disease. Journal of Clinical Ethics 2: 219–228. (discussion 228–240).Google Scholar
  54. 54.
    Emanuel, E.J., and L.L. Emanuel. 1992. Four models of the physician–patient relationship. Jama 267: 2221–2226.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2008

Authors and Affiliations

  1. 1.Department for Neurodegenerative DiseasesHertie-Institute for Clinical Brain Research, University of TübingenTübingenGermany
  2. 2.Department of Medical EthicsUniversity of TübingenTübingenGermany

Personalised recommendations