Cosmetic neurology

Peripheral transcutaneous electrical stimulation to improve cognition: a review of the main effects in healthy humans and in mildly cognitively impaired patient populations

Peripheral nerve stimulation (PNS) is an ancient technique, up to now mainly used for pain management. The least invasive approach for PNS is transcutaneous electrical stimulation (TENS), which is performed by delivering mild electric currents through the skin and, depending on the stimulation pattern, activates the somatosensory Aβ-, Aδ- and C-fibers. In addition to its use for pain relief, accumulating data indicates that TENS can have broad-spectrum cognitive effects through the activation of neuromodulatory brain pathways. This review aims to summarize the current evidence on the cognitive effects of TENS, from healthy participants and mildly cognitively affected patients. Most studies on this topic have investigated the effects of TENS on memory, while fewer studies have explored attention, executive functions, and verbal fluency. Overall, promising evidence suggests that TENS may exert positive effects on specific cognitive functions. Further research is needed to build consensus on the most effective stimulation protocols, for both neurorehabilitation and enhancement, and to better understand the neurobiological mechanisms underlying the cognitive effects of TENS.

Public Views on Whether the Use of Pharmaceutical Neuroenhancements Should Be Allowed

BACKGROUND AND OBJECTIVES

Some individuals are using drugs to try to enhance cognitive and social-affective functioning and asking physicians for off-label prescriptions for neuroenhancement (e.g., stimulants). Several medical societies released guidance on prescribing neuroenhancers, some of which refer to potential societal effects of neuroenhancement (e.g., distributive justice), besides risks and benefits to users. Which institutions (e.g., medical societies, government, universities) should make decisions on allowing neuroenhancement and whether they should consider potential societal effects are unclear. We examined whether and how much support for allowing pharmaceutical neuroenhancers was influenced by the institution and potential individual and societal effects of neuroenhancers.

METHODS

We conducted a discrete-choice experiment using a constructed representative sample of the US adult public. Multinomial logit models were used to analyze the data.

RESULTS

Participants (n = 927) demographically resembled the US population. Risks of serious side effects (OR 0.20, CI 0.18-0.22) and a lack of benefits for users (OR 0.31, CI 0.26-0.38) had the largest negative effect on participants' support for allowing neuroenhancers. A risk of mild side effects had a moderate negative effect on participants' support for allowing neuroenhancers (OR 0.67, CI 0.62-0.74) and the prospect of more meaningful, long-lasting benefits for users a moderate positive effect (OR 1.74, CI 1.61-1.87). Positive or negative effects of neuroenhancers on the average well-being of people in society and on equality had moderate effects on participants' support for allowing neuroenhancers. For example, the odds of participants' support for allowing enhancers with a negative effect on societal well-being were around half (OR 0.45, CI 0.40-0.50) and the odds of allowing enhancers that worsen inequality were approximately 40% lower compared with enhancers without such effects (OR 0.62, CI 0.55-0.71). The odds of participants allowing neuroenhancers were slightly (10%) lower if enhancers reduced users' authenticity (OR 0.90, CI 0.84-0.97). The institution regulating neuroenhancers and neuroenhancers providing users with an unfair advantage did not affect participants' decisions.

DISCUSSION

When presented with both individual and societal considerations, the public seems to support medical societies and other institutions making policy decisions about neuroenhancers based on risks and benefits for users, as well as, but to a lesser extent, effects on equality and societal well-being.

Cosmetic psychiatry: A concept in urgent need of consideration

OBJECTIVE

To explore the concept of, ethics surrounding, and arguments for and against cosmetic psychiatry.

CONCLUSIONS

Cosmetic psychiatry may be defined as the science and practice of interventions that subjectively enhance the mental states of healthy people. Cosmetic medicine (including surgery) is a professionally and socially accepted part of contemporary medical practice; cosmetic psychiatry is not. Like cosmetic medicine, there are significant risks associated with cosmetic psychiatry. There is an urgent need for a broader conversation about this emerging clinical reality.

One hundred years of neurosciences in the arts and humanities, a bibliometric review

BACKGROUND

Neuroscientific approaches have historically triggered changes in the conception of creativity and artistic experience, which can be revealed by noting the intersection of these fields of study in terms of variables such as global trends, methodologies, objects of study, or application of new technologies; however, these neuroscientific approaches are still often considered as disciplines detached from the arts and humanities. In this light, the question arises as to what evidence the history of neurotechnologies provides at the intersection of creativity and aesthetic experience.

METHODS

We conducted a century-long bibliometric analysis of key parameters in multidisciplinary studies published in the Scopus database. Screening techniques based on the PRISMA method and advanced data analysis techniques were applied to 3612 documents metadata from the years 1922 to 2022. We made graphical representations of the results applying algorithmic and clusterization processes to keywords and authors relationships.

RESULTS

From the analyses, we found a) a shift from a personality-focus quantitative analysis to a field-focus qualitative approach, considering topics such as art, perception, aesthetics and beauty; b) The locus of interest in fMRI-supported neuroanatomy has been shifting toward EEG technologies and models based on machine learning and deep learning in recent years; c) four main clusters were identified in the study approaches: humanistic, creative, neuroaesthetic and medical; d) the neuroaesthetics cluster is the most central and relevant, mediating between creativity and neuroscience; e) neuroaesthetics and neuroethics are two of the neologism that better characterizes the challenges that this convergence of studies will have in the next years.

CONCLUSIONS

Through a longitudinal analysis, we evidenced the great influence that neuroscience is having on the thematic direction of the arts and humanities. The perspective presented shows how this field is being consolidated and helps to define it as a new opportunity of great potential for future researchers.

Cooperative behavior in the workplace: Empirical evidence from the agent-deed-consequences model of moral judgment

Introduction

Moral judgment is of critical importance in the work context because of its implicit or explicit omnipresence in a wide range of work-place practices. The moral aspects of actual behaviors, intentions, and consequences represent areas of deep preoccupation, as exemplified in current corporate social responsibility programs, yet there remain ongoing debates on the best understanding of how such aspects of morality (behaviors, intentions, and consequences) interact. The ADC Model of moral judgment integrates the theoretical insights of three major moral theories (virtue ethics, deontology, and consequentialism) into a single model, which explains how moral judgment occurs in parallel evaluation processes of three different components: the character of a person (Agent-component); their actions (Deed-component); and the consequences brought about in the situation (Consequences-component). The model offers the possibility of overcoming difficulties encountered by single or dual-component theories.

Methods

We designed a 2 × 2 × 2-between-subjects design vignette experiment with a Germany-wide sample of employed respondents (N = 1,349) to test this model.

Results

Results showed that the Deed-component affects willingness to cooperate in the work context, which is mediated via moral judgments. These effects also varied depending on the levels of the Agent- and Consequences-component.

Discussion

Thereby, the results exemplify the usefulness of the ADC Model in the work context by showing how the distinct components of morality affect moral judgment.

Autonomy, procedural and substantive: a discussion of the ethics of cognitive enhancement

As cognitive enhancement research advances, important ethical questions regarding individual autonomy and freedom are raised. Advocates of cognitive enhancement frequently adopt a procedural approach to autonomy, arguing that enhancers improve an individual's reasoning capabilities, which are quintessential to being an autonomous agent. On the other hand, critics adopt a more nuanced approach by considering matters of authenticity and self-identity, which go beyond the mere assessment of one's reasoning capacities. Both positions, nevertheless, require further philosophical scrutiny. In this paper, we investigate the ethics of cognitive enhancement through the lenses of political and philosophical arguments about autonomy and freedom. In so doing, we contend that a substantive, relational account of individual autonomy offers a more holistic understanding of the ethical concerns of cognitive enhancement.

Consumo de psicoestimulantes por estudantes de medicina de uma universidade do extremo sul do Brasil

Objetivo: analisar a evolução do consumo de psicoestimulantes pelos acadêmicos de Medicina da Universidade Federal do Rio Grande (FURG) durante quatro anos.Métodos: foi realizado um estudo de painel com amostra de estudantes do primeiro ao quarto ano do curso de medicina, matriculados na instituição no período de 2015 a 2018. O estudo teve como desfecho o consumo de psicoestimulantes. Foram coletadas informações sobre o uso de cafeína, metilfenidato, piracetam, modafinil, bebidas energéticas, metilenodioximetanfetamina (ecstasy) e anfetaminas. O questionário foi composto de duas etapas. Na primeira, foram recolhidas informações demográficas, sobre hábitos e qualidade de vida. Na segunda, questionou-se sobre o consumo de substâncias estimulantes, abordando a frequência de uso, efeitos percebidos e a motivação para o consumo, assim como o início do consumo durante o curso.Resultados: a prevalência de uso dessas substâncias aumentou de 58% para 68% de 2015 a 2018. A proporção de acadêmicos que começaram a usar psicoestimulantes durante a faculdade, aumentou de 15% para 30%. Essa proporção aumentou conforme o ano do curso, passando de 25% no primeiro ano para 38% no quarto ano. Esse resultado foi atribuído, principalmente, ao uso de metilfenidato, cuja prevalência aumentou de 21% para 56% durante o período do estudo.Conclusões: o consumo de psicoestimulantes entre estudantes de medicina foi alto e o início de seu consumo durante a faculdade aumentou ao longo dos anos. Seu uso tem sido percebido como eficaz pela maioria dos usuários, o que pode dificultar o gerenciamento do uso indevido dessas substâncias.

Public Opinion on Cognitive Enhancement Varies across Different Situations

People vary widely in their acceptance of the use of pharmacological cognitive enhancement (CE). We tested the hypothesis that the acceptability of CE is malleable, by varying the context in which CE use takes place, by framing the use of CE with positive and negative metaphors, and by distinguishing between self and other CE use. 2,519 US-based participants completed 2 surveys using Amazon's Mechanical Turk. First, participants responded to vignettes describing a fictional character, which varied by framing metaphor (Pandora's box that releases brain performance vs. key that unlocks brain potential), role/setting (student/educational vs. employee/professional), and activity type (blue vs. white collar). Second, participants viewed personalized vignettes describing their own situations. Across both surveys, participants generally found CE use more acceptable for employees than students, while the effects of framing metaphors were unreliable and smaller than previously reported. People were more accepting of CE use by others than by themselves. Participants also found CE use more acceptable if more peers used CE, the environment was less competitive, and authority figures encouraged CE use. Our findings suggest that opinions about CE are indeed malleable, and concerns that peer pressure, the influence of authority figures, and competition might affect CE use are not unfounded.

APRIMORAMENTO COGNITIVO FARMACOLÓGICO: MOTIVAÇÕES CONTEMPORÂNEAS

O objetivo deste artigo, de caráter teórico descritivo, foi analisar as principais motivações para o aprimoramento cognitivo farmacológico na contemporaneidade, mediante o diálogo com autores que investigaram alguns fenômenos da denominada pós-modernidade, tais como Deleuze (1992), Foucault (2000), Bauman (2001) e Han (2015), além de autores do campo psicanalítico (Bezerra Júnior, 2010; Ferraz, 2014; Birman, 2014) que tecem críticas à questão da medicalização da educação e seus desdobramentos. Constatou-se que, na atualidade, a busca pelo aprimoramento cognitivo farmacológico está intimamente ligada ao estilo de vida e ao de sociedade construídos nas últimas décadas. Independentemente da palavra utilizada para nomear o momento histórico vivido, está cada vez mais difícil lidar com a realidade e, nesse contexto, o aprimoramento cognitivo farmacológico revela-se como uma das facetas do fenômeno recente conhecido como psiquiatrização da normalidade. Como resultado, nota-se também que o uso não médico e indiscriminado de medicamentos para ‘turbinar’ o cérebro tem tornado uma prática comum entre os estudantes universitários; por esse motivo, não se trata meramente de uma questão educacional relacionada à interferência nos processos de ensino e de aprendizagem, mas de um problema de saúde pública. Conclui-se que esse fenômeno suscita, na sociedade atual, desafios de diferentes ordens, razão pela qual merece atenção especial da comunidade científica.

Attitudes Toward Cognitive Enhancement: The Role of Metaphor and Context

The widespread use of stimulants among healthy individuals to improve cognition has received growing attention; however, public attitudes toward this practice are not well understood. We determined the effect of framing metaphors and context of use on public opinion toward cognitive enhancement. We recruited 3,727 participants from the United States to complete three surveys using Amazon's Mechanical Turk between April and July 2017. Participants read vignettes describing an individual using cognitive enhancement, varying framing metaphors (fuel versus steroid), and context of use (athletes versus students versus employees). The main outcome measure was the difference in respondent-assigned level of acceptability of the use of cognitive enhancement by others and by themselves between the contrasting vignettes. Participants were more likely to support the use of cognitive enhancement by others than by themselves and more when the use of enhancement by others was framed with a fuel metaphor than with a steroid metaphor. Metaphoric framing did not affect participants' attitudes toward their own use. Participants supported the use of enhancement by employees more than by students or athletes. These results are discussed in relation to existing ethical and policy literature.

Smarter Than Thou, Holier Than Thou: The Dynamic Interplay Between Cognitive and Moral Enhancement

The debate about the desirability of using drugs to enhance human skills encompasses cognitive abilities such as memory and attention, and moral capacities such as emotional empathy and a sense of fairness. These two strands of literature in bioethics have grown relatively independent from each other, and an implicit framing assumption has emerged suggesting that apparently morally neutral cognitive capacities and paradigmatically moral capacities are distinct and vary independently of each other. Here, we identify key distinctions between competing accounts of cognitive enhancement and moral enhancement and argue that, despite the polarized nature of the bioethical debate, cognitive and moral capacities are intertwined. For example, moral behavior can be improved by enhancing "morally neutral" abilities such as attention span; and cognitive skills can be honed by means of socio-moral interaction. Further, cognitive skill is frequently assigned the abstract status of virtue and treated in the same way as more paradigmatically "moral" traits. We argue that the distinction between moral and cognitive enhancement is more apparent than real, since despite being nominally treated as distinct, cognitive and moral skills are frequently interdependent. As such we present evidence to support the claim that the enhancement of these two kinds of capacities cannot be clearly disaggregated from each other in the way that the theoretical poles of the debate in the literature suggest. We synthesize relevant scientific and bioethical literature and combine it with a line of analysis derived from Peter Hacker to show more clearly the terms of what can be said intelligibly about cognitive and moral skills and their enhancement. As a result of this analysis, we conclude that ethical questions in human bioenhancement are only fully intelligible at the level of persons imbued with feelings, thoughts, intentions, desires, values, and abilities, embedded within a particular social context, rather than at the level of pharmacological modulation of particular cognitive or affective capacities which, though conceptually distinguishable, in the embodied context of moral agency are profoundly intertwined.

Pharmacological cognitive enhancement in pediatrics

PURPOSE OF REVIEW

Given the pervasiveness of psychotropic medication in the youth population and an increasingly competitive culture regarding educational performance, children, teenagers, and/or their parents may increasingly seek psychotropic substances in an effort to enhance a student's cognitive abilities and/or academic performance. Physicians must become aware of this very important and clinically relevant issue and work to ensure that medications remain in the hands of patients seeking wellness and not enhancement.

RECENT FINDINGS

The current article highlights findings on the pervasiveness of stimulant misuse and diversion in youth, the motivations and effects of stimulant use, health and legal consequences associated with use, and physician perceptions and preventive practices. Ethical concerns regarding pharmacological cognitive enhancement in pediatrics are also outlined - including coercion for nonusers, inequities in access, and threats to an individual's sense of self with regard to authenticity and autonomy.

SUMMARY

Pharmacological cognitive enhancement in pediatrics will become a larger, clinically relevant issue in the coming years. Physicians who care for children and adolescents must become more aware of this issue. Given the myriad health, legal, and ethical concerns, clinicians should discourage use of pharmaceuticals for enhancement purposes in the pediatric population.

Memory-Modulation: Self-Improvement or Self-Depletion?

Autobiographical memory is fundamental to the process of self-construction. Therefore, the possibility of modifying autobiographical memories, in particular with memory-modulation and memory-erasing, is a very important topic both from the theoretical and from the practical point of view. The aim of this paper is to illustrate the state of the art of some of the most promising areas of memory-modulation and memory-erasing, considering how they can affect the self and the overall balance of the “self and autobiographical memory” system. Indeed, different conceptualizations of the self and of personal identity in relation to autobiographical memory are what makes memory-modulation and memory-erasing more or less desirable. Because of the current limitations (both practical and ethical) to interventions on memory, I can only sketch some hypotheses. However, it can be argued that the choice to mitigate painful memories (or edit memories for other reasons) is somehow problematic, from an ethical point of view, according to some of the theories of the self and personal identity in relation to autobiographical memory, in particular for the so-called narrative theories of personal identity, chosen here as the main case of study. Other conceptualizations of the “self and autobiographical memory” system, namely the constructivist theories, do not have this sort of critical concerns. However, many theories rely on normative (and not empirical) conceptions of the self: for them, the actions aimed at mitigating or removing specific (negative) memories can be seen either as an improvement or as a depletion or impairment of the self.

Moral Enhancement Using Non-invasive Brain Stimulation

Biomedical enhancement refers to the use of biomedical interventions to improve capacities beyond normal, rather than to treat deficiencies due to diseases. Enhancement can target physical or cognitive capacities, but also complex human behaviors such as morality. However, the complexity of normal moral behavior makes it unlikely that morality is a single capacity that can be deficient or enhanced. Instead, our central hypothesis will be that moral behavior results from multiple, interacting cognitive-affective networks in the brain. First, we will test this hypothesis by reviewing evidence for modulation of moral behavior using non-invasive brain stimulation. Next, we will discuss how this evidence affects ethical issues related to the use of moral enhancement. We end with the conclusion that while brain stimulation has the potential to alter moral behavior, such alteration is unlikely to improve moral behavior in all situations, and may even lead to less morally desirable behavior in some instances.

Cognitive and Performance Enhancing Medication Use to Improve Performance in Poker

Use of neuroenhancers has been studied in groups ranging from students to surgeons; however, use of cognitive and performance enhancing medications (CPEMs) to improve performance in poker has remained largely overlooked. To assess the use of CPEMs to improve poker performance, a survey of poker players was conducted. Participants were recruited via Internet poker forums; 198 completed the online survey. Approximately 28 % of respondents used prescription CPEMs, with the most commonly used including: amphetamine/dextroamphetamine (62 %), benzodiazepines (20 %), and methylphenidate (20 %). CPEMs were used in poker to focus (73 %), calm nerves (11 %), and stay awake (11 %). Caffeine (71 %), as well as conventionally counter-intuitive substances like marijuana (35 %) and alcohol (30 %) were also reported to enhance poker performance. Non-users of CPEMs were dissuaded from use due to not knowing where to get them (29 %), apprehension about trying them (26 %), and legal or ethical concerns (16 %). Respondents most frequently acquired CPEMs via friends/fellow poker players (52 %), or prescription from physician (38 %). Additionally, greater use of CPEMs was associated with living outside the United States (p = 0.042), prior use of prescription medications for improving non-poker related performance (p < 0.001), and amateur and semi-professional player status (p = 0.035). Unmonitored use of pharmacologically active agents and their methods of acquisition highlight safety concerns in this cohort of poker players, especially among non-professional players. The current state of guidance from national organizations on CPEM use in healthy individuals could impact prescribing patterns.

Pharmacological cognitive enhancement: treatment of neuropsychiatric disorders and lifestyle use by healthy people

Neuropsychiatric disorders typically manifest as problems with attentional biases, aberrant learning, dysfunctional reward systems, and an absence of top-down cognitive control by the prefrontal cortex. In view of the cost of common mental health disorders, in terms of distress to the individual and family in addition to the financial cost to society and governments, new developments for treatments that address cognitive dysfunction should be a priority so that all members of society can flourish. Cognitive enhancing drugs, such as cholinesterase inhibitors and methylphenidate, are used as treatments for the cognitive symptoms of Alzheimer's disease and attention deficit hyperactivity disorder. However, these drugs and others, including modafinil, are being increasingly used by healthy people for enhancement purposes. Importantly for ethical and safety reasons, the drivers for this increasing lifestyle use of so-called smart drugs by healthy people should be considered and discussions must occur about how to ensure present and future pharmacological cognitive enhancers are used for the benefit of society.

The warrior in the machine: neuroscience goes to war

Ever since Stone Age men discovered that knapping flint produced sharp stone edges that could be used in combat as well as for cooking and hunting, technological advances of all kinds have been adapted and adopted by the military.The opportunities provided by modern neuroscience are proving no exception, but their application in a military context is accompanied by complex practical and ethical considerations.

"Messing with the mind": evolutionary challenges to human brain augmentation

The issue of brain augmentation has received considerable scientific attention over the last two decades. A key factor to brain augmentation that has been widely overlooked are the complex evolutionary processes which have taken place in evolving the human brain to its current state of functioning. Like other bodily organs, the human brain has been subject to the forces of biological adaptation. The structure and function of the brain, is very complex and only now we are beginning to understand some of the basic concepts of cognition. Therefore, this article proposes that brain-machine interfacing and nootropics are not going to produce “augmented” brains because we do not understand enough about how evolutionary pressures have informed the neural networks which support human cognitive faculties.

What's Special about the Ethical Challenges of Studying Disorders with Altered Brain Activity?

Where there is no viable alternative, studies of neuronal activity are conducted on animals. The use of animals, particularly for invasive studies of the brain, raises a number of ethical issues. Practical or normative ethics are enforced by legislation, in relation to the dominant welfare guidelines developed in the United Kingdom and elsewhere. Guidelines have typically been devised to cover all areas of biomedical research using animals in general, and thus lack any specific focus on neuroscience studies at the level of the ethics, although details of the specific welfare recommendations are different for invasive studies of the brain. Ethically, there is no necessary distinction between neuroscience and other biomedical research in that the brain is a final common path for suffering, irrespective of whether this involves any direct experience of pain. One exception arises in the case of in vitro studies, which are normally considered as an acceptable replacement for in vivo studies. However, to the extent sentience is possible, maintaining central nervous system tissue outside the body naturally raises ethical questions. Perhaps the most intractable challenge to the ethical use of animals in order to model neuronal disorder is presented by the logical impasse in the argument that the animal is similar enough to justify the validity of the experimental model, but sufficiently different in sentience and capacity for suffering, for the necessary experimental procedures to be permissible.

Pharmacological cognitive enhancement-how neuroscientific research could advance ethical debate

There are numerous ways people can improve their cognitive capacities: good nutrition and regular exercise can produce long-term improvements across many cognitive domains, whilst commonplace stimulants such as coffee temporarily boost levels of alertness and concentration. Effects like these have been well-documented in the medical literature and they raise few (if any) ethical issues. More recently, however, clinical research has shown that the off-label use of some pharmaceuticals can, under certain conditions, have modest cognition-improving effects. Substances such as methylphenidate and modafinil can improve capacities such as working memory and concentration in some healthy individuals. Unlike their more mundane predecessors, these methods of “cognitive enhancement” are thought to raise a multitude of ethical issues. This paper presents the six principal ethical issues raised in relation to pharmacological cognitive enhancers (PCEs)—issues such as whether: (1) the medical safety-profile of PCEs justifies restricting or permitting their elective or required use; (2) the enhanced mind can be an “authentic” mind; (3) individuals might be coerced into using PCEs; (4), there is a meaningful distinction to be made between the treatment vs. enhancement effect of the same PCE; (5) unequal access to PCEs would have implications for distributive justice; and (6) PCE use constitutes cheating in competitive contexts. In reviewing the six principal issues, the paper discusses how neuroscientific research might help advance the ethical debate. In particular, the paper presents new arguments about the contribution neuroscience could make to debates about justice, fairness, and cheating, ultimately concluding that neuroscientific research into “personalized enhancement” will be essential if policy is to be truly informed and ethical. We propose an “ethical agenda” for neuroscientific research into PCEs.

Generating genius: how an Alzheimer's drug became considered a 'cognitive enhancer' for healthy individuals

Background

Donepezil, an acetylcholinesterase inhibitor used in the treatment of Alzheimer’s disease, has been widely cited in media and bioethics literature on cognitive enhancement (CE) as having the potential to improve the cognitive ability of healthy individuals. In both literatures, this claim has been repeatedly supported by the results of a small study published by Yesavage et al. in 2002 on non-demented pilots (30–70 years old). The factors contributing to this specific interpretation of this study’s results are unclear.

Methods

We examined print media and interdisciplinary bioethics coverage of this small study, aiming to provide insight into how evidence from research may be shaped within different discourses, potentially influencing important policy, ethics, and clinical decisions. Systematic qualitative content analysis was used to examine how this study was reported in 27 media and 22 bioethics articles. Articles were analyzed for content related to: (1) headlines and titles; (2) colloquialisms; and, (3) accuracy of reporting of the characteristics and results of the study.

Results

In media and bioethics articles referencing this small study, strong claims were made about donepezil as a CE drug. The majority of headlines, titles, and colloquialisms used enhancement language and the majority of these suggest that donepezil could be used to enhance intellectual ability. Further, both literatures moved between reporting the results of the primary study and magnifying the perceived connection between these results and the CE debate that was alluded to in the primary study. Specific descriptions of the results overwhelmingly reported an improvement in performance on a flight simulator, while more general statements claimed donepezil enhanced cognitive performance. Further, a high level of reporting accuracy was found regarding study characteristics of the original study, but variable levels of accuracy surrounded the presentation of complex characteristics (i.e., methods) or contentious properties of the CE debate (i.e., initial health status of the study subjects).

Conclusions

Hyped claims of CE effects cannot be completely accounted for by sheer inaccuracy in reporting. A complex interaction between the primary and secondary literature, and expectations and social pressures related to CE appears to drive enthusiastic reports.

Cosmetic neurology: the role of healthcare professionals

In an age of modern technology and an increasing movement towards a 24-h working culture, life for many is becoming more stressful and demanding. To help juggle these work commitments and an active social life, nootropic medication, (the so-called 'smart pills') have become a growing part of some people's lives. Users claim that these drugs allow them to reach their maximal potential by becoming more efficient, smarter and requiring less sleep. The use of these medications and the role of health professionals in their distribution raises many ethical questions.

Law, ethics, and the clinical neurologist

There is dynamic interplay between the disciplines of law and ethics, and the result is often laws and regulation that impact the practice of clinical neurology. This chapter explores how the disciplines of law and ethics inform and intersect with each other, and how resulting law impacts the everyday work of the clinical neurologist. Examples of how the core bioethical principles of nonmaleficence, beneficence, respect for autonomy, and justice are manifest in legislative, common, and administrative laws are presented. Examples of how these laws, in turn, impact the practice of neurology through protection of patient privacy, the avoidance of conflict of interest, and informed consent and other issues are offered.

Is neuroenhancement by noninvasive brain stimulation a net zero-sum proposition?

In the past several years, the number of studies investigating enhancement of cognitive functions through noninvasive brain stimulation (NBS) has increased considerably. NBS techniques, such as transcranial magnetic stimulation and transcranial current stimulation, seem capable of enhancing cognitive functions in patients and in healthy humans, particularly when combined with other interventions, including pharmacologic, behavioral and cognitive therapies. The "net zero-sum model", based on the assumption that brain resources are subjected to the physical principle of conservation of energy, is one of the theoretical frameworks proposed to account for such enhancement of function and its potential cost. We argue that to guide future neuroenhancement studies, the net-zero sum concept is helpful, but only if its limits are tightly defined.

The neurobiology of modafinil as an enhancer of cognitive performance and a potential treatment for substance use disorders

RATIONALE AND OBJECTIVES

Modafinil (MOD) and its R-enantiomer (R-MOD) are approved medications for narcolepsy and other sleep disorders. They have also been used, off-label, as cognitive enhancers in populations of patients with mental disorders, including substance abusers that demonstrate impaired cognitive function. A debated nonmedical use of MOD in healthy individuals to improve intellectual performance is raising questions about its potential abuse liability in this population.

RESULTS AND CONCLUSIONS

MOD has low micromolar affinity for the dopamine transporter (DAT). Inhibition of dopamine (DA) reuptake via the DAT explains the enhancement of DA levels in several brain areas, an effect shared with psychostimulants like cocaine, methylphenidate, and the amphetamines. However, its neurochemical effects and anatomical pattern of brain area activation differ from typical psychostimulants and are consistent with its beneficial effects on cognitive performance processes such as attention, learning, and memory. At variance with typical psychostimulants, MOD shows very low, if any, abuse liability, in spite of its use as a cognitive enhancer by otherwise healthy individuals. Finally, recent clinical studies have focused on the potential use of MOD as a medication for treatment of drug abuse, but have not shown consistent outcomes. However, positive trends in several result measures suggest that medications that improve cognitive function, like MOD or R-MOD, may be beneficial for the treatment of substance use disorders in certain patient populations.

Use of illicit and prescription drugs for cognitive or mood enhancement among surgeons

BACKGROUND

Surgeons are usually exposed to high workloads leading to fatigue and stress. This not only increases the likelihood of mistakes during surgery but also puts pressure on surgeons to use drugs to counteract fatigue, distress, concentration deficits, burnout or symptoms of depression. The prevalence of surgeons taking pharmacological cognitive enhancement (CE) or mood enhancement (ME) drugs has not been systematically assessed so far.

METHODS

Surgeons who attended five international conferences in 2011 were surveyed with an anonymous self-report questionnaire (AQ) regarding the use of prescription or illicit drugs for CE and ME and factors associated with their use. The Randomized Response Technique (RRT) was used in addition. The RRT guarantees a high degree of anonymity and confidentiality when a person is asked about stigmatizing issues, such as drug abuse.

RESULTS

A total of 3,306 questionnaires were distributed and 1,145 entered statistical analysis (response rate: 36.4%). According to the AQ, 8.9% of all surveyed surgeons confessed to having used a prescription or illicit drug exclusively for CE at least once during lifetime. As one would expect, the prevalence rate assessed by RRT was approximately 2.5-fold higher than that of the AQ (19.9%; 95% confidence interval (CI), 15.9% to 23.9%, N = 1,105). An even larger discrepancy between the RRT and AQ was observed for the use of antidepressants with a 6-fold higher prevalence (15.1%; 95% CI, 11.3% to 19.0%, N = 1,099) as compared to 2.4% with the AQ. Finally, logistic regression analysis revealed that pressure to perform at work (odds ratio (OR): 1.290; 95% CI, 1.000 to 1.666; P = 0.05) or in private life (OR: 1.266; 95% CI, 1.038 to 1.543; P = 0.02), and gross income (OR: 1.337; 95% CI, 1.091 to 1.640; P = 0.005), were positively associated with the use of drugs for CE or ME.

CONCLUSIONS

The use of illicit and prescription drugs for CE or ME is an underestimated phenomenon among surgeons which is generally attributable to high workload, perceived workload, and private stress. Such intake of drugs is associated with attempts to counteract fatigue and loss of concentration. However, drug use for CE may lead to addiction and to overestimation of one's own capabilities, which can put patients at risk. Coping strategies should be taught during medical education.

Positive Clinical Neuroscience

Disorders of the brain and its sensory organs have traditionally been associated with deficits in movement, perception, cognition, emotion, and behavior. It is increasingly evident, however, that positive phenomena may also occur in such conditions, with implications for the individual, science, medicine, and for society. This article provides a selective review of such positive phenomena – enhanced function after brain lesions, better-than-normal performance in people with sensory loss, creativity associated with neurological disease, and enhanced performance associated with aging. We propose that, akin to the well-established field of positive psychology and the emerging field of positive clinical psychology, the nascent fields of positive neurology and positive neuropsychology offer new avenues to understand brain-behavior relationships, with both theoretical and therapeutic implications.

Metilfenidato e aprimoramento cognitivo farmacológico: representações sociais de universitários

O artigo tem por objetivo apresentar o resultado da investigação das representações sociais de 20 estudantes universitários sobre o uso de metilfenidato para aprimorar o desempenho cognitivo em pessoas saudáveis. Nesta pesquisa qualitativa, de cunho exploratório, 20 universitários entre 18 e 25 anos, oriundos de cursos das áreas de saúde e humanas, foram distribuídos em três grupos focais para debater sobre o Aprimoramento Cognitivo Farmacológico. A análise dos dados revelou que entre esses estudantes houve uma maior tolerância aos métodos que alteram a neurobiologia a favor do ideal social de melhoria da performance das pessoas. Contudo, os entrevistados expressaram grande preocupação com a possibilidade de este procedimento vir a intensificar injustiças e desigualdades entre as pessoas, principalmente nas sociedades em que já existem significativas diferenças sociais. Assim, apesar de o tema ser pouco estudado no Brasil, a análise dos dados da presente investigação sugere que o Aprimoramento Cognitivo Farmacológico é um assunto atual e relevante. Não apenas por esta prática estar relacionada à construção e manutenção da subjetividade dos indivíduos em uma sociedade que prioriza a melhoria da performance cognitiva, mas também pelo risco de esta interferir em questões de igualdade e justiça social.

Rethinking the thinking cap: ethics of neural enhancement using noninvasive brain stimulation

Although a growing body of evidence suggests that noninvasive brain stimulation techniques such as transcranial magnetic stimulation and transcranial direct current stimulation have the capacity to enhance neural function in both brain-injured and neurally intact individuals, the implications of their potential use for cosmetic self-enhancement have not been fully explored. We review 3 areas in which noninvasive brain stimulation has the potential to enhance neurologic function: cognitive skills, mood, and social cognition. We then characterize the ethical problems that affect the practice of cosmetic neurology, including safety, character, justice, and autonomy, and discuss how these problems may apply to the use of noninvasive brain stimulation for self-enhancement.

Neuroethical issues in cognitive enhancement

Neuroethics is a developing field, concerned with addressing present and future applied ethical issues brought about directly and indirectly by neuroscience advancements. One domain where neuroscience has begun to have far-reaching ethical implications is in the research and development of pharmaceutical cognitive enhancers. Though such drugs are typically developed to treat cognitive disabilities and improve the quality of life for patients with neuropsychiatric disorders and brain injury, research has found that such drugs can improve performance on cognitive tasks in healthy individuals. In line with such findings is the growing use of these drugs by students and others for cognitive-enhancing purposes. The present paper reviews some of the evidence in both neuropsychiatric and healthy individuals and discusses the implications such research can have for society.

Reining in the pharmacological enhancement train: we should remain vigilant about regulatory standards for prescribing controlled substances

This article challenges recent assumptions that physicians may ethically and legally prescribe psychopharmacological enhancement drugs to patients and the counterintuitive notion that in some cases ingesting an enhancement drug constitutes the more ethical choice than foregoing this option. Enhancement proponents have touted modafinil as an ideal mechanism to improve concentration, alertness, and forego sleep and keep pace with our society's demands. However, patients who use modafinil for these reasons risk potentially severe side effects and addiction, and face unintended consequences related to their cognitive, emotive, and physiological functioning. Importantly, prescribing a controlled substance such as modafinil for performance enhancement and sleep avoidance runs contrary to a physician's ethical duty to the patient and the standard of practice set forth in legal requirements governing the prescription of controlled substances.