Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a neurologist should prescribe a stimulant ("Big A") off-label for an airplane pilot to improve her performance.
Should the doctor prescribe Big A?
Yes: 29%
No: 70%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Nootropics are medications that improve cognitive performance in various ways. These might include improvements in memory, arousal, and concentration.
Some, including caffeine, are already in widespread use. Others, such as the stimulant amphetamine/dextroamphetamine (Adderall) and the wakefulness-promoting agent modafinil (Provigil), are available only through a prescription or on the extensive black market.
For certain individuals, notably patients with attention-deficit/hyperactivity disorder (ADHD) or narcolepsy, nootropics help treat their illnesses and allow them to function at the level of their peers. For others, these same medications are believed to -- and sometimes do -- improve performance above the norm.
Yet the line between therapy and enhancement is a blurry one. In many settings, the use of performance-enhancing drugs may be viewed as "cheating."
For instance, much as baseball players are not allowed to inject steroids, some ethicists argue that using amphetamines to study for the SAT gives students an unfair advantage. Critics, of course, note that there are a host of unfair advantages related to SAT preparation that certain students possess and others so not. Wealthy students hire tutors, do not have to work jobs that cut into study time, and can more easily find quiet places to learn without distraction. Why should one prohibit nootropic use but not SAT tutors?
Of course, SAT tutors impose very little medical risk. In contrast, amphetamines pose a wide variety of risks and side effects, including addiction potential. These risks might justify banning the use of such drugs for enhancement, but it is a mistake to conflate this argument about danger with concern for unfair advantages.
Probably the most significant threat posed by nootropics is the potential that patients will feel pressured or forced to use them.
From Camille's encounter with Dr. Lydgate, it appears that Big A use is now expected of certain pilots -- including those who might not want to assume the long-term medical risks of taking the medication. One woman's ceiling, as the expression goes, is another woman's floor. If widespread Big A use raises the performance standards for pilots to a level where nonusers cannot compete, anyone interested in flying commercial jets will be forced, in practice, to opt for cognitive enhancement.
Nootropics have the potential to create a "new normal," against which all participants will be judged. That might prove problematic for a prospective airplane pilot, but it might also be somewhat reassuring to a potential passenger, should it turn out that these agents actually do render air travel safer.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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