Cosmetic neurology
The controversy over enhancing movement, mentation, and mood

Dr. Russo's comments, and the reactions elicited by my colleagues, highlight again the need for active engagement by the neurologic community in the use of neurologic enhancement technologies. The problem here, as with many bioethical issues, is that reasonable people will often disagree. Our community has two obligations, I think. The first, as stated eloquently by Dr. Dees, must be to support the traditional view of the physician-patient relationship which required that the physician always act in the best interest of the individual patient. Even this mandate is not black and white however. Consider the situation in which acting in the best interest of the patient may conflict with the goal of improving public health. We willingly vaccinate our patients against polio for the purpose of maintaining herd immunity (rather than providing individual protection), even though vaccination carries a risk-albeit miniscule-of neuroparalytic complications. From his military vantage point, Dr. Russo provides a very interesting and important example in which the greater good is not that of public health but that of combat readiness, public welfare, and the national interest. Perhaps the military should distinguish between a personal physician whose role is to prepare troops for battle. In such a situation one would hope that the personal physician is given the final say over any therapeutic option suggested (or imposed) by the combat physician. By analogy, professional athletes have long been aware of the potential conflict of interest inherent in their relationship with team physicians. And usually seek opinions of independent experts before undergoing treatment for sports injuries. They recognize that team physicians may be subtly (or not so subtly) incentivized to return the player to the field as soon as possible. An egregious example of this type of potential conflict occurred several years ago in professional baseball; in this case the team physician was also a member of the ownership group.

Our second obligation, and the purpose of the editorial, was to suggest that we must as a profession provide expert and evidence-based data on the risks and benefits of interventions that enhance neurologic functions.

The use of neuroenhancements in the military noted by Drs. Russo et al is an unwitting case study in the concerns about safety, coercion, and the role of physicians that Dr. Chatterjee [1] , Dr. Hauser [2] , and I [3] raised in our articles.

Although the military may have good reasons for maintaining secrecy, the rest of us should not be expected to rely on what the military says to make our judgments about the safety of a drug or a procedure. The authors argue that the use of dextroamphetamine is safe, because they have seen no reports of adverse effects, of dependency with "operational" use, or of flight surgeon's over-prescribing them. We have to take their word for it because the data are not available outside the military—assuming that they are available within the military. We should never accept the unreviewed testimony of any researcher, and we should be especially skeptical when the institution involved, be it the military or a pharmaceutical company, has strong reasons to make the rest of us accept a particular finding.

Second, the military is a coercive institution. I suspect that if the soldiers are not actually ordered to take these drugs, their superiors let it be known that they are expected to do so. At minimum, it is represented to them that their lives and those of the members of their unit are at stake if they fail to take these drugs. The soldiers thus do not have a meaningful choice about whether they can take the drugs or not. Such coercion is perhaps justifiable, but only if an important ethical goal can not be achieved in any other way. In addition, the drugs could easily be subject to "mission creep." While situations in which these drugs are needed may sometimes be unavoidable in war, the availability of such drugs makes the assignment of sleep-depriving missions easier. With these drugs available, the military is likely to assign missions to fewer soldiers rather than build in the sleep requirements that humans normally require. As a result, the use of these drugs will simply become a routine part of their job.

Third, the authors' role in prescribing neuroenhancing drugs for soldiers under their care raises general questions about the doctor- patient relationship. The authors believe that, as military physicians, they have responsibilities to both the health of "our military members and of our nation." These two responsibilities may conflict , especially if the desires of the military become equated in some people's minds with the needs of the nation. In that spirit, some military doctors at Abu Ghraib and Guantanamo Bay thought it ethical to advise interrogators about their prisoners' vulnerabilities. The authors, of course, claim a much more modest use of this principle: they only claim that "when battles may be won or lost," that "it would be unethical not to provide" performance- enhancing drugs for the "warriors" in their care. Nevertheless, the doctors do not prescribe these drugs to better their patients' health, but to enable their soldiers to perform their lethal jobs better and thereby to advance what they perceive to be the greater good. When doctors begin to act on their own perception of the greater good, they can begin to treat their patients not as the individuals that need care, but as cogs in a war machine. Even if the war in which they are participating is a just war—even if it is a war for survival—doctors violate the deepest duties of their profession when they lose sight of the individuals they are supposed to help. If physicians keep their focus squarely on their patients, they will be better off ethically, and the rest of us will be better off medically.

Acknowledgments The author thanks Jonathan Mink, David Goldblatt, and Jennifer Kwon for comments on earlier drafts of this response.

References

1. Chatterjee A. Cosmetic neurology: The controversy over enhancing movement, mentation, and mood. Neurology 2004; 63: 968-74.

2. Hauser SL. The shape of things to come. Neurology 2004;63:948-50.

3. Dees RH. Slippery slopes, wonder drugs, and cosmetic neurology. Neurology 2004;63:951-52.

4. Bloche MG and Marks JH. When doctors go to war. New England Journal of Medicine 2005;352:3-6.

I appreciate Russo et al's comments about cosmetic neurology and their confirmation of my speculation that much research conducted on soldiers will not reach the public domain. I am also heartened that there are no reports of amphetamine dependency or abuse within any of the services, no reports of coercive prescribing practices among flight surgeons, and that military research shows that the benefits of modafinil outweigh the risks.

I do not consider what military practitioners do, or cosmetic neurology for that matter, to be shallow or superficial. While the term cosmetic has come to be associated with appearance rather than essence, it is rooted in the Greek word "kosmetikos", which refers to skill in arranging. My point [1] was to discuss ways in which cosmetic neurology involves skilled neurologic arrangements that penetrate our very notions of personhood, and the promise and predicaments that follow. The questions I pose are: Can you be more than you can be? Should you?

The healthy human has vast, untapped potential. Neurologists do not need to create new neural capability or alter individual essence. In the military, we would be remiss if we did not seek to improve performance in sleep-restricted environments. When American warriors can not sleep, when their lives are at stake, and when battles may be won or lost based upon ability to sustain performance, it would be unethical for the military not to provide a rational and well-researched fatigue countermeasure doctrine.

Dextroamphetamine can lead to dependence. However, there are no reports of dependency or abuse with operational use, and there are no reports of flight surgeons over-prescribing or forcing countermeasures upon service members. There are no accidents or performance errors associated with the correct use of countermeasures. The incident of the U.S. Air Force pilots erroneously firing on Canadian forces in Afghanistan, while alleged by legal defense, was not substantiated as a contributing factor linked to their use of dextroamphetamine.

Chatterjee refers to research with sleep-deprived helicopter pilots [1], and comments that only the tip of this research may reach the public domain. Chatterjee is correct, much of the work is published in technical reports (see www.USAARL.army.mil) rather than in peer-reviewed literature, and much is not published at all. However, a vast amount of peer- reviewed information on pharmacological interventions to sustain performance in healthy humans is available through a literature search of John Caldwell. [2]

Chatterjee questions the safety of modafinil for use in healthy individuals, commenting that it may improve performance in some areas while impairing it in others. This is a serious concern. Application of countermeasures must balance cost with benefit. If judgment, decision- making, and other cognitive processes are impaired rather than improved, the cost of using the countermeasure may outweigh the benefits. This is a topic of current study.

Military practitioners are among the most carefully regulated physicians. We understand the responsibility to assure the health and safety of our military members and of our nation. Research to tap into the healthy human's underutilized capacity may be called enhancement. This form of enhancement is an important contribution to not only society, but also to aging individuals who experience naturally-occurring cognitive declines. Cosmetic neurology is not what military neurologists practice; this implies our efforts are shallow or superficial.

Rather, neurologists may ethically and honorably help healthy individuals optimize their cognitive potential.

References

Reference

1) Chatterjee A. Cosmetic Neurology: the controversy over enhancing movement, mentation and mood. Neurology 2004;63:968-974.

2) Caldwell, JA, Caldwell, JL, Smythe, NK, Hall, KK. A double-blind, placebo-controlled investigation of the efficacy of modafinil for sustaining the alertness and performance of aviators: a helicopter simulator study. Psychopharmacology, 150:272-282, 2000.