Cosmetic neurology

Physician attitudes towards pharmacological cognitive enhancement: safety concerns are paramount

The ethical dimensions of pharmacological cognitive enhancement have been widely discussed in academic circles and the popular media, but missing from the conversation have been the perspectives of physicians - key decision makers in the adoption of new technologies into medical practice. We queried primary care physicians in major urban centers in Canada and the United States with the aim of understanding their attitudes towards cognitive enhancement. Our primary hypothesis was that physicians would be more comfortable prescribing cognitive enhancers to older patients than to young adults. Physicians were presented with a hypothetical pharmaceutical cognitive enhancer that had been approved by the regulatory authorities for use in healthy adults, and was characterized as being safe, effective, and without significant adverse side effects. Respondents overwhelmingly reported increasing comfort with prescribing cognitive enhancers as the patient age increased from 25 to 65. When asked about their comfort with prescribing extant drugs that might be considered enhancements (sildenafil, modafinil, and methylphenidate) or our hypothetical cognitive enhancer to a normal, healthy 40 year old, physicians were more comfortable prescribing sildenafil than any of the other three agents. When queried as to the reasons they answered as they did, the most prominent concerns physicians expressed were issues of safety that were not offset by the benefit afforded the individual, even in the face of explicit safety claims. Moreover, many physicians indicated that they viewed safety claims with considerable skepticism. It has become routine for safety to be raised and summarily dismissed as an issue in the debate over pharmacological cognitive enhancement; the observation that physicians were so skeptical in the face of explicit safety claims suggests that such a conclusion may be premature. Thus, physician attitudes suggest that greater weight be placed upon the balance between safety and benefit in consideration of pharmacological cognitive enhancement.

Responding to requests from adult patients for neuroenhancements: guidance of the Ethics, Law and Humanities Committee

In the last decade, persons who have no diagnosed medical or mental health condition are increasingly seeking and utilizing, for the ostensible purpose of enhancing their memory or cognitive skills, prescription drugs that were originally developed to improve executive function or memory in persons diagnosed with disorders such as attention deficit hyperactivity disorder or Alzheimer disease. Evidence suggests that this practice, now known as neuroenhancement, is gathering momentum. As a result, neurologists may be encountering patients without a diagnosed illness asking for medications with the goal of improving their memory, cognitive focus, or attention span. Strong arguments have been made for and against this practice, often reflecting strongly held convictions concerning the appropriate practice of medicine. The purpose of this report is to provide neurologists with an overview of the ethical, legal, and social issues surrounding the use of pharmaceuticals prescribed to enhance or augment normal cognitive or affective functioning, as well as practical guidance for responding to an adult patient's request for neuroenhancement.

Cognitive enhancement: methods, ethics, regulatory challenges

Cognitive enhancement takes many and diverse forms. Various methods of cognitive enhancement have implications for the near future. At the same time, these technologies raise a range of ethical issues. For example, they interact with notions of authenticity, the good life, and the role of medicine in our lives. Present and anticipated methods for cognitive enhancement also create challenges for public policy and regulation.

Beyond Neurobiological Reductionism

This paper examines the neurobiological explanatory trend in psychology, including the related and tacit roles of ontological materialism and reductionism. In addition, the role of Cartesian dualism in both psychology and cognitive neuroscience is explored. In both, the complex relationships between mind/brain and mind/body tend to be conceptualized through the framework of either ontic dualism or attribute dualism, both of which ultimately constrain notions of embodiment. Alternatively, this paper understands the body as the inseparable unity of being-in-the-world from which the Cartesian dichotomy of “mind” and “body” is abstracted. This alternative surpasses the constraints of dualism and reframes embodiment as intentionality incarnate and ultimately as “flesh.” The body, understood phenomenologically, emerges not as a “what” but as a “ what—how”—the manifestation in extension of our intentionality, the flesh of our projects in and of the world. We argue that this understanding is indispensable to a properly psychological perspective on embodiment.

[Neuroethics in clinical practice]

In recent years the ability of neuroscience to identify and intervene in mental functions has progressed immensely, which raises several anthropologic and ethical questions. Meanwhile neuroethics arose as a new interdisciplinary field for critical analysis of neuroscientific actions and ethical reflection on the increasing knowledge of the human brain, with regard to society and politics. This article provides a survey of neuroethical implications for clinical practice.

Disagreements with implications: diverging discourses on the ethics of non-medical use of methylphenidate for performance enhancement

Background

There is substantial evidence that methylphenidate (MPH; Ritalin), is being used by healthy university students for non-medical motives such as the improvement of concentration, alertness, and academic performance. The scope and potential consequences of the non-medical use of MPH upon healthcare and society bring about many points of view.

Methods

To gain insight into key ethical and social issues on the non-medical use of MPH, we examined discourses in the print media, bioethics literature, and public health literature.

Results

Our study identified three diverging paradigms with varying perspectives on the nature of performance enhancement. The beneficial effects of MPH on normal cognition were generally portrayed enthusiastically in the print media and bioethics discourses but supported by scant information on associated risks. Overall, we found a variety of perspectives regarding ethical, legal and social issues related to the non-medical use of MPH for performance enhancement and its impact upon social practices and institutions. The exception to this was public health discourse which took a strong stance against the non-medical use of MPH typically viewed as a form of prescription abuse or misuse. Wide-ranging recommendations for prevention of further non-medical use of MPH included legislation and increased public education.

Conclusion

Some positive portrayals of the non-medical use of MPH for performance enhancement in the print media and bioethics discourses could entice further uses. Medicine and society need to prepare for more prevalent non-medical uses of neuropharmaceuticals by fostering better informed public debates.

Unintended changes in cognition, mood, and behavior arising from cell-based interventions for neurological conditions: ethical challenges

The prospect of using cell-based interventions (CBIs) to treat neurological conditions raises several important ethical and policy questions. In this target article, we focus on issues related to the unique constellation of traits that characterize CBIs targeted at the central nervous system. In particular, there is at least a theoretical prospect that these cells will alter the recipients' cognition, mood, and behavior-brain functions that are central to our concept of the self. The potential for such changes, although perhaps remote, is cause for concern and careful ethical analysis. Both to enable better informed consent in the future and as an end in itself, we argue that early human trials of CBIs for neurological conditions must monitor subjects for changes in cognition, mood, and behavior; further, we recommend concrete steps for that monitoring. Such steps will help better characterize the potential risks and benefits of CBIs as they are tested and potentially used for treatment.

Taare Zameen Par and dyslexic savants

The film Taare Zameen Par (Stars upon the Ground) portrays the tormented life at school and at home of a child with dyslexia and his eventual success after his artistic talents are discovered by his art teacher at the boarding school. The film hints at a curious neurocognitive phenomenon of creativity in the midst of language disability, as exemplified in the lives of people like Leonardo da Vinci and Albert Einstein, both of whom demonstrated extraordinary creativity even though they were probably affected with developmental learning disorders. It has been hypothesized that a developmental delay in the dominant hemisphere most likely 'disinhibits' the nondominant parietal lobe, unmasking talents-artistic or otherwise-in some such individuals. It has been suggested that, in remedial training, children with learning disorders be encouraged to develop such hidden talents to full capacity, rather than be subjected to the usual overemphasis on the correction of the disturbed coded symbol operations.

The law and neuroscience

Some of the implications for law of recent discoveries in neuroscience are considered in a new program established by the MacArthur Foundation. A group of neuroscientists, lawyers, philosophers, and jurists are examining issues in criminal law and, in particular, problems in responsibility and prediction and problems in legal decision making.

[Autonomy in medicine. Self-determination, self-design and shaping one's own life]

Autonomy is a central and multifaceted concept of ethical reflection with many nuances of meaning. Central to the concept are the ability and opportunity to self-determine and self-design, as well as the potential to shape the course of one's own life significantly. However, there is generally a narrow understanding of the concept in the debate on patient autonomy and informed consent in a medico-therapeutic context, to which the possibility to a free decision-making process based on concrete treatment scenarios is central. In contrast, the present article discusses the diversity of autonomy-related aspects in non-therapeutic areas of medicine, while underlining the need to further develop and differentiate the concept of autonomy.

Coming to our senses: appreciating the sensorial in medical anthropology

This article supports the call for the sensorially engaged anthropological study of healing modalities, popular health culture, dietary practices, drug foods and pharmaceuticals, and idioms of distress. Six concepts are of central importance to sensorial anthropology: embodiment, the mindful body, mimesis, local biology, somatic idioms of distress, and 'the work of culture'. Fieldwork in South and Southeast Asia and North America illustrates how cultural interpretations associate bodily sensations with passions (strong emotions) and anxiety states, and bodily communication about social relations. Lay interpretations of bodily sensations inform and are informed by local understanding of ethnophysiology, health, illness, and the way medicines act in the body. Bodily states are manipulated by the ingestion of substances ranging from drug foods (e.g., sources of caffeine, nicotine, dietary supplements) to pharmaceuticals that stimulate or suppress sensations concordant with cultural values, work demands, and health concerns. Social relations are articulated at the site of the body through somatic modes of attention that index bodily ways of knowing learned through socialization, bodily memories, and the ability to relate to how another is likely to be feeling in a particular context. Sensorial anthropology can contribute to the study of transformative healing and trajectories of healthcare seeking and patterns of referral in pluralistic healthcare arenas.

Human subjects protections in biomedical enhancement research: assessing risk and benefit and obtaining informed consent

The protection of human subjects in biomedical research relies on two principal mechanisms: assessing and comparing the risks and potential benefits of proposed research, and obtaining potential subjects' informed consent. While these have been discussed extensively in the literature, no attention has been paid to whether the processes should be different when the objective of an experimental biomedical intervention is to improve individual appearance, performance, or capability ("enhancement research") rather than to prevent, cure, or mitigate disease ("health-oriented research"). This essay examines this question in order to ensure that subjects in biomedical enhancement research receive adequate protection.

Neurophilosophical perspectives of neuroimaging in forensic psychiatry-giving way to a paradigm shift?

Forensic psychiatry is concerned with the relationship between psychiatric abnormalities and legal violations and crimes. Due to the lack of available biological criteria, evaluation and therapy in forensic psychiatry have so far been restricted to psychosocial and mental criteria of offenders' personalities. Recent advances in neurosciences allow a closer approach to the neural correlates of personality, moral judgments and decision-making. We propose to discuss the introduction of biological criteria in the field of forensic psychiatry and to establish rules as to what extent such biological criteria will be a better and more reliable choice in judging mentally ill criminals by using all available information that can be obtained by biological means. Psychosocial and subjective criteria in forensic evaluation will be more and more accomplished by biopsychosocial and objective criteria. The responsibility of having committed a criminal act will no longer be exclusively defined by judging free and voluntary decision-making, but rather by brain-behavior relationships. What is often referred to as psychosocially determined mental processes thus could be complemented by estimating the degree of biopsychosocially determined neural processes. We conclude that such a process could contribute to a paradigm shift in forensic psychiatry, which will have profound implications for offenders, forensic psychologists and psychiatrists, the law and society in general.

Memory enhancing drugs and Alzheimer's disease: enhancing the self or preventing the loss of it?

In this paper we analyse some ethical and philosophical questions related to the development of memory enhancing drugs (MEDs) and anti-dementia drugs. The world of memory enhancement is coloured by utopian thinking and by the desire for quicker, sharper, and more reliable memories. Dementia is characterized by decline, fragility, vulnerability, a loss of the most important cognitive functions and even a loss of self. While MEDs are being developed for self-improvement, in Alzheimer's Disease (AD) the self is being lost. Despite this it is precisely those patients with AD and other forms of dementia that provide the subjects for scientific research on memory improvement. Biomedical research in the field of MEDs and anti-dementia drugs appears to provide a strong impetus for rethinking what we mean by 'memory', 'enhancement', 'therapy', and 'self'. We conclude (1) that the enhancement of memory is still in its infancy, (2) that current MEDs and anti-dementia drugs are at best partially and minimally effective under specific conditions, (3) that 'memory' and 'enhancement' are ambiguous terms, (4) that there is no clear-cut distinction between enhancement and therapy, and (5) that the research into MEDs and anti-dementia drugs encourages a reductionistic view of the human mind and of the self.

Neuroethical responsibilities

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the French-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.

The will to health: a Nietzschean critique

The purpose of this paper is to propose a critique of the prevailing attitude of human health, what I refer to as the will to health, using a Nietzschean perspective. First, I briefly discuss the purpose and manner of Nietzsche's methodological approach to philosophy and his problem with modernity. Second, I explicate the two current ideological paradigms of health that, in my view, constitute the prevailing will to health. Third, Nietzsche's general understanding of human health is presented and following this, a critique of some contemporary health matters from this perspective is undertaken. Strictly speaking, there is no specific thesis to be found in this paper. I do not presume to prove or disprove anything, rather I avail myself of Nietzsche's unique insight into the human condition as a rubric from which to illuminate something of the nature of human health.

Bioethical Issues in Medicinal Chemistry and Drug Treatment

The use of drugs to treat human disease is a pursuit that extends back into our evolutionary ancestors. Drugs are powerful substances with a great capacity to cause harm if misused or overused. Even when used correctly, pharmaceuticals can elicit disputes about their relative harms and benefits in specific situations. The establishment of modern intermediaries – physicians or pharmacists – in the allocation of the most powerful drugs increases the potential for conflict between those who control the resource and those who desire access to it. The size and influence of the pharmaceutical–industrial complex places disproportionate power in those whose interests lie in promoting and expanding pharmaceutical use in society. The expense of certain drugs complicates equitable allocation, and the concentration of pharmaceutical power in Western, industrialized countries promotes research and drug discovery disproportionately for diseases that are prevalent in the wealthier nations. The increasing sophistication of drug action challenges the traditional model of using drugs as a means to treat pathological conditions and processes, and raises the specter of lifestyle and enhancement uses of pharmaceuticals. New means of drug discovery – such as the use of stem cells – have elicited debate about the relative values placed on the status of the embryo and the potential treatment for intractable conditions that could result from stem cell research. Finally, the overall emphasis on drugs as the first line defense against what ails us has provoked some societal soul-searching. In this chapter, we review some of the ethical issues attendant to drug production and distribution, including issues of safety, justice, economic inequality, and the changing demands for drugs that exceed therapeutic uses. Suggestions are made to make pharmaceutical companies more responsive to these issues and to make oversight bodies more responsible for their roles.

Ethical issues in neuroscience

PURPOSE OF REVIEW

The study gives an overview of ethical questions raised by the progress of neuroscience in identifying and intervening in neural correlates of the mind.

RECENT FINDINGS

Ethical problems resulting from brain research have induced the emergence of a new discipline termed neuroethics. Critical questions concern issues, such as prediction of disease, psychopharmacological enhancement of attention, memory or mood, and technologies such as psychosurgery, deep-brain stimulation or brain implants. Such techniques are capable of affecting the individual's sense of privacy, autonomy and identity. Moreover, reductionist interpretations of neuroscientific results challenge notions of free will, responsibility, personhood and the self which are essential for western culture and society. They may also gradually change psychiatric concepts of mental health and illness. These tendencies call for thorough, philosophically informed analyses of research findings and critical evaluation of their underlying conceptions of humans.

SUMMARY

Advances in neuroscience raise ethical, social and legal issues in relation to the human person and the brain. Potential benefits of applying neuroimaging, psychopharmacology and neurotechnology to mentally ill and healthy persons have to be carefully weighed against their potential harm. Questions concerning underlying concepts of humans should be actively dealt with by interdisciplinary and public debate.

Neuroethics: a modern context for ethics in neuroscience

Neuroethics, a recently modernized field at the intersection of bioethics and neuroscience, is founded on centuries of discussion of the ethical issues associated with mind and behavior. Broadly defined, neuroethics is concerned with ethical, legal and social policy implications of neuroscience, and with aspects of neuroscience research itself. Advances in neuroscience increasingly challenge long-held views of the self and the individual's relationship to society. Neuroscience also has led to innovations in clinical medicine that have not only therapeutic but also non-therapeutic dimensions that extend well beyond previously charted boundaries. The exponential increase in cross-disciplinary research, the commercialization of cognitive neuroscience, the impetus for training in ethics, and the increased attention being paid to public understanding of science all illuminate the important role of neuroethics in neuroscience.

Responsabilités Neuroéthiques

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the English-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.

Revolutions and shifting paradigms in human factors & ergonomics

The "Revolution in Information Technology" has spawned a series of transformational revolutions in the nature and practice of human factors and ergonomics (HFE). "Generation 1" HFE evolved with a focus on adapting equipment, workplace and tasks to human capabilities and limitations. Generation 2, focused on cognitive systems integration, arose in response to the need to manage automation and dynamic function allocation. Generation 3 is focused on symbiotic technologies that can amplify human physical and cognitive capabilities. Generation 4 is emergent and is focused on biological enhancement of physical or cognitive capabilities. The shift from HFE Generations 1 and 2 to Generations 3 and 4 profoundly alters accepted boundary constraints on the adaptability of humans in complex systems design. Furthermore, it has opened an ethical divide between those that see cognitive and physical enhancement as a great benefit to society and those who perceive this as tampering with the fundamentals of human nature.

Neurocognitive Enhancement: Ethical Considerations for an Emerging Subspecialty

Clinical neuropsychology has traditionally focused on the diagnosis and treatment of pathology. However, recent technological advances have begun to make possible the enhancement of healthy neurocognitive functioning. The potential to improve normal neurocognitive abilities, and the options for providing such improvement, raise complex ethical issues. To best serve consumers, the profession, and society, neuropsychologists must begin to consider the ethical issues related to neurocognitive enhancement. This article reviews neurocognitive enhancement methods, introduces and examines ethical issues that emerge when the enhancement of healthy neurocognitive functioning is considered, and offers recommendations for neuropsychologists entering this emerging subspecialty.