A DISCUSSION ON COGNITIVE ENHANCEMENT AND MEDICAL PROFESSIONALS

CDM II Ethics Project Jayanth Swathirajan, MS2 and Kenneth Koncilja, MS2 March 28, 2011

Case of Gunner Syndrome

Jay is an M3, an eager beaver medical student out on wards. He is performing his surgery rotation and is required to be on call for 36 straight hours. The night before his scheduled call night, he is out late with some friends watching his alma mater, the University of Michigan, play a basketball game followed by a midnight showing of the latest Star Wars movie. He is not drinking, knowing that he has call the next evening. When on wards the next day, Jay is feeling tired and is having trouble remember what orders he placed, is forgetting patient HPIs, and has no idea how he will be able to stand in surgery for any prolonged period of time. Instead of telling his resident that he is sleep deprived, Jay borrows some of his roommates Adderall. Jay is able to perform competently for the rest of the shift and effectively care for his patients.

Was he right to use abuse a cognitive stimulant? How often does this occur? Should all physicians be using stimulants? How does this compromise patient care? All of these questions and more will be analyzed through this two part position paper divided into a pro-con format. These arguments are not meant to be taken as completely right or completely wrong, but to be viewed as guides for issues needing to be considered in the debate over stimulant use by health care providers and medical students.

ARGUMENT FOR COGNITIVE ENHANCEMENT

Cognitive enhancement is a growing field both in medicine and in the outside world. The phrase cognitive enhancement refers to improving the psychological function of individuals who are not ill (Farah, 421). Enhancing ones mind is an important topic for discussion as individuals, especially highly performing ones, look to further enhance their cognitive abilities. As with any other instance where medicine looks to not just treat individuals, but attempts to solely enhance patients lives, the issue of cognitive enhancement faces questions regarding its ethical appropriateness. The purpose of this section is to promote the idea that cognitive enhancement is appropriate for all individuals, especially those in the medical field. Cognitive enhancement can be achieved through many different means. The primary area of focus in the medical and popular press regards the use of psychopharmacology. Drugs affecting psychological processes have become very sophisticated such that scientists are able to target specific receptors and yield distinct neurological phenotypes. The most popular psychopharmacologic drugs used in neuroenhancement are drugs targeting Attention Deficit Hyperactive Disorder (ADHD), Aderall and Methylphenidate, and modafinil (source: Boosting Brain Power). Although the ADHD drugs are meant to treat people with the condition, they can have profound effects on healthy individuals. These include increased attentiveness, alertness, vigilence and improved psychomotor and executive functioning (Webb 206). Modafinil, a drug initially intended for treatment of narcolepsy, is now more frequently prescribed to maintain alertness for those who work long night-time shifts, such as physicians and those in the military (source: Boosting Brain Power).

The beneficial effects to cognitive function listed above have motivated many to seek out these drugs. The most frequently studied population that has used cognitive enhancers is college students. According to a widely cited study, seven percent of US university students have taken stimulants for non-medical reasons (Szalavitz). The news-magazine program 60 Minutes, on April 25, 2010, featured a segment named Boosting Brain Power in which college students were interviewed as to the effects of pharmacologic neuro-enhancers. They said that it was common practice on campus and used to get an edge on the rest of the students (Boosting Brain Power). The means by which college students use to procure drugs are through friends or colleagues who have clinically diagnosed ADHD but do not use all of their pills. Furthermore, according to the feature, the act of using drugs to enhance cognitive function is growing in popularity amongst older individuals, especially in academia. Although cognitive enhancement appears to be popular, it is widely regarded as unethical. For one, many are using controlled substances, therefore making this act illegal. However, is it possible that cognitive enhancement may be acceptable? There are many arguments suggesting that the public should accept the use of cognitive enhancement. One argument in favor of cognitive enhancement is that drugs simply represent one way to enhance our well-being. Society has already accepted many methods to improve human well being, such as cosmetic plastic surgery. In the same way, we should use cognitive enhancers to further enhance our mental capacity. Although some may use drugs as an extra supplement, beyond our normal means of enhancement, we already use drugs such as caffeine to artificially enhance our cognition. Therefore, why should all drugs be lumped in as summarily evil? (Greely 702-

3) An important ethical principle that is evident in cognitive enhancement therapy is that of Justice. Procurement of neuroenhancing drugs may involve considerable financial investments that all individuals may not possess. However, this has not stopped the formation of tutors and preparatory courses that are only available for affluent students, therefore why should it stop the progress of cognitive enhancers? (Greely 703) The use of cognitive enhancement has great potential in the field of medicine, populated by high achieving individuals who must function at all hours of the day. The bioethical principle that is appropriate in this situation is beneficence, doing what is best for the patients interest. Physicians who are tired or not alert have the potential to do tremendous harm to their patients. One particular study suggested that a sleep deprived physician has the mental capacity of a mildly intoxicated individual. Furthermore, it has been statistically proven that physicians who are post-call are more likely to be involved in motor vehicle accidents. Therefore, with these risks in mind, it makes sense to allow physicians to partake in measures that would alleviate this risk factor (Webb 208). To further the argument of safety with respect to drug therapy, the medical field has made one particular stimulant, caffeine, an accepted practice. Most involved in the medical care consume some form of caffeine. However, it too is a stimulant that has a side effect profile that is worse than modafinil (Webb 207-8). Therefore what is the purpose for the double standard? Furthermore, some in the medical field are already partaking in pharmacologic-aided cognitive enhancement. Many surgeons take beta blockers to steady their hands and some physicians take modafinil when on a long call (Webb 207). The ethical conundrum of particular interest to the medical field is that of competitive advantage. This is especially seen in medical school as students strive to

achieve the best grades possible. However, the competitive advantage argument is a largely superfluous one. After the preclinical medical school years, the primary goal surrounds patient care, not the means the physician uses to provide this care. Therefore, if medical personnel are more alert and able to perform with the use of cognitive enhancers, they will be less likely to make errors and will be able to serve their patients better. Even for medical students and residents, if the use of cognitive enhancement allows them to absorb more information, they may be able to become better physicians (Webb 207). Since the use of cognitive enhancement has merit, it should be further investigated. Although there are many potential benefits, some therapies have potentially devastating side effects; therefore its use must be monitored. As stated earlier, many individuals are already using cognitive therapy, therefore the scientific and medical community must come together to outline standards for their use. Currently, cognitive enhancement has remained the domain of backhanded black-market dealings. Physicians, as gatekeepers of these medications, must decide the appropriate action to take regarding this matter. Cognitive enhancement is an appropriate therapy that must be reviewed.

ARGUMENT AGAINSTDRUGGED PROVIDERS

The use of stimulants has spread from therapeutic use in the treatment of disease to use as a cognitive enhancer in students ranging from middle school to medical school. Spreading abuse has entered medical schools and impacts the way future physicians learn. An ethical interpretation is vital for understanding the true

implications of the status quo drug emporium. The end of alert physicians does not justify the means of illicit drug abuse compromising provider health. The illegal use of Attention Deficit Hyperactivity Disorder (ADHD) stimulants negatively impact physician wellness and patient safety. Rules and expectations of illegal drug abuse should be made clear to uphold the integrity of the profession and the quality of care. With most situations of drug abuse, the paramount issue is physicians who are impaired or incompetent might harm patients (do no harm). Illicit use of cognitive stimulants is no different. The profession must be able to police the use of stimulants to protect both patient and physician health. Although most students use their ADHD medication as prescribed, misuse and diversion is not uncommon (Rabinar 1). Because enhancing academic performance is the primary motive for misuse in college students, the reality is abuse is changing the way our students learn. Changing learning environments and methods of learning affect the attitudes and motivations of healthcare providers. Care provided by future physicians begins to morph into an ambiance of career advancement and drug-driven quality performance. No longer are patients the center of care; our physician performance and achievement is on a pedestal for the drug enhanced provider.

Why do medical students feel driven to engage in performance drug abuse? The answer is best found in a world of competition, where the best are rewarded and the slow are in last. One of the largest reasons advocates support the use of cognitive stimulants is to increase wakefulness and decrease fatigue from long work hours seen by medical students (Webb). There is an easy solution to this problem: open up more slots for graduate medical education, support further work hour restrictions, and promote medical student wellness. A physician-in-training living a healthy lifestyle is better able to relate to patients without seeming hypocritical. Medical schools could provide low-cost healthy food items, offer safe locations for undisturbed sleep, and encourage students to budget physical fitness into the preparation hours required to study specific clerkship disciplines. Wellness, not stimulant drug abuse, is the best way to improve physician alertness and attentiveness. Action now by medical schools to create a learning environment where positive self-care is valued could enhance the personal well-being of medical students now and begin a movement toward improved personal health care for physicians in the future (Estabrook 1). Wellness is the issue, not chemical manipulation of our neurocognitive function. To enter a service profession is to put the best foot forward to care for the patients and not to take the easy way out. Medical schools need to allow the top to set a tone, a world where attending physicians and residents promote healthy balanced lifestyles for medical students by setting stable examples in their own lives. The actual ethical dilemma of a medical student abusing a cognitive enhancer is clear cut cheating in the short term with a long term consequence of reduced patient care. The health care of the medical student is at serious risk. There are cases of

myocardial infarction in students using cognitive enhancers to study (Xiangyang). The fact that the medical student is at such a high risk of serious adverse outcome is alone a red flag warning us that this might not be sound ethical use. Stimulants change the way the provider thinks.Patients have a right to know if their medical student is high on a drug like Adderall because it is affecting the kind of care they receive But what about caffeine?Every time we look around it seems like another provider, nurse, or doctor drinks coffee. Caffeine is a cognitive stimulant; where it

differs from the ADHD drugs is in its legality and commonly accepted use. The form used should be in the form acceptable to the general patient population (pop beverages, coffee, and tea). Medical schools should promote education of safe legal stimulant use and include physician-in-training wellness as part of the medical student curriculum. Caffeine pill use is not a medically acceptable form and is not in any prescribed package on personal wellness. Bioethical principles should guide our investigation into ethical patient centered care. Beneficence ensures that the action is truly for the good of the patient. The health of the physician should be considered as leading to the best patient out come. Nonmaleficence ensures providers are not committing harmful actions; stimulant abuse is a harm to the user and to the patient, who becomes tolerant of the drug-abuse. What kind of message of values does a drugged physician send to our patients? Integrity is an essential element of the physician-patient relationship. Simulant use distance the ability of the physician to relate to the patient, worsens the effectiveness of the physician long term, and is a form of cheating if used by an undergraduate medical

student or a graduate student resident or fellow. The bioethical value of honesty directs full disclosure of an intoxicated physician having exposure to innocent patients. On the first day of orientation at the University of Toledo College of Medicine, we were told medicine is tough; that our education will be like trying to drink water from a fire hydrant. They love that analogy. This attitude and mindset predisposes our

students to look for shortcuts, often at the expense of their own health and that of their patients. Medical schools and our health care system should look to improved health and provider/student wellness as the best ways to improve patient care. Illegal

stimulant abuse is dangerous to providers and patients. The medical community must work together to ban stimulant abuse in the classroom and on the floors.

Works Cited
Arria, Amelia M. Nonmedical Use of Prescription Stimulants Among College Students: Associations with Attention-DeficitHyperactivity Disorder and Polydrug Use. PHARMACOTHERAPY Volume 28, Number 2, 2008 Cetta, Denise S., prod. "Boosting Brain Power." 60 Minutes. 25 Apr. 2010. Television. Diller, Lawrence. ADHD in the College Student: Is Anyone Else Worried? Journal of Attention Disorders.Volume 14 Number 1.July 2010 3-6. Estabrook, Kristi. Medical Student Health Promotion: The Increasing Role of Medical Schools. Acad Psychiatry 32:65-68, January-February 2008. Farah, Martha J., Judy Illes, Robert Cook-Deegan, Howard Gardner, Eric Kandel, Patricia King, Eric Parens, Barbara Sahakian, and Paul Root Wolpe. "Science and Society: Neurocognitive Enhancement: What Can We Do and What Should We Do?" Nature Reviews Neuroscience 5.5 (2004): 421-25. Print. Greely, Henry. "Access : Towards Responsible Use of Cognitive-enhancing Drugs by the Healthy : Nature." Nature Publishing Group : Science Journals, Jobs, and Information. May 2004. Web. 13 Feb. 2011. <http://www.nature.com/nature/journal/vaop/ncurrent/full/456702a.html>. Rabiner, David. The Misuse and Diversion of Prescribed ADHDMedications by College Students Journal of Attention Disorders Volume 13 Number 2 September 2009 144153. Szalavitz, Maia. "Popping Smart Pills: The Case for Cognitive Enhancement." Time Magazine6 Jan. 2009. Web. Webb, Jardon. Contemplating Cognitive Enhancement in Medical Students and Residents.Perspectives in Biology and Medicine, volume 53, number 2 (spring 2010):200214. The Johns Hopkins University Press. Xiangyang Jiao. Myocardial Infarction Associated with Adderall XR and Alcohol Use in a Young Man. JABFM MarchApril 2009 Vol. 22 No. 2.