BIOETHICS

The End of Impairment?

Generation Rx Goes to Medical School

Roughly 20,000 people enter medical school in America annually, and in the 2006-2007 academic year, the American Council of Graduate Medical Education reported 106,383 residents in 8,355 accredited programs. Medical training entails mastery of physical, moral, and intellectual challenges; failure brings harsh consequences. Medical students have first the stress of earning an MD, then of residency to specialize. A 2006 survey of 2,737 first-year residents found that those who worked five or more 24-hour or longer shifts in one month were three times as likely to report committing fatal errors as people who worked less.[1] A recent study screened 123 self-selected residents at three urban children’s hospitals for depression and burn out. Twenty percent were considered depressed and 74 percent burnt out. Nurses and physicians working with depressed residents reported that group made medication errors six times as often as non-depressed residents.[2]

This situation arises from a particular pharmaceutical landscape, and young medical professionals indicate future trends and current issues.

Consequently, medical neophytes may feel pressure from within and without to maintain their edge. Nine current and recent residents around the country and one medical student all spoke to me on condition of anonymity for themselves and their programs in order to recount their experiences without fear of embarrassing or implicating anyone. According to this group, they and their peers frequently imbibe alcohol to relax and caffeine to stay alert, and some legally get antidepressants. However, a minority turns illegally to ubiquitous medications. “You can’t just not show up for work one day,” an anesthesiology resident said, “no matter how crappy you feel—so you grab a Zofran out of the dispenser, or you get one of your friends to write you the antibiotic for an infection that you might not have but you’re afraid not to treat it. Being in office settings, you have easy access to all the meds the drug reps bring, so yeah, you’re inclined to grab a handful of Zoloft or whatever and see if it helps.”

Few medical professionals have quite this attitude or access. Nonetheless, the demand to be at one’s mental best is constant. One obstetrician/gynecologist “ate a lot of blueberries because I heard they improved memory.” Meanwhile, the above anesthesiologist’s roommate crushed and snorted “illegally obtained” Ritalin to study, and a neurologist knew four or five people “who’d taken other people’s Ritalin to stay up late to study for exams.” A third resident had once used her brother’s Ritalin in conjunction with caffeine to study in high school but decided not to do it again.

Because these students and residents are not using the drugs to make up for normal abilities they lack, but rather to enhance their performance, they effectively raise the standards for “normalcy,” and the ethical questions get complicated. But this situation arises from a particular pharmaceutical landscape, and young medical professionals indicate future trends and current issues.

By 1999, the United States was consuming 85 percent of the global supply of methylphenidate, a stimulant packaged as Ritalin and Concerta, to treat attention deficit hyperactivity disorder, commonly known as ADHD.[3] Methylphenidate and similar drugs can help healthy people—not by overcoming a deficit—but by allowing them to exceed their normal abilities. Ritalin, for instance, can improve spatial working memory, and Provigil (the marketing name for modafinil), designed to alleviate narcolepsy, can increase accuracy on mental tasks.[4] Since Ritalin, Provigil, and others are not prescribed for cognitive enhancement, it is illegal to use them thus. Yet over 20 studies in the last decade show people do.[5]

A review of those studies showed 5 to 9 percent of students through twelfth grade reported use of a “nonprescribed stimulant” in the last year, often Ritalin or Adderall (amphetamine and dextroamphetamine), as did 5 to 35 percent of college-aged respondents. Sixteen to 29 percent of people with prescriptions for stimulants had given away or sold the drug in their lifetime. Some people used these drugs to party, others to concentrate and elevate productivity.[6] Following a December 2007 commentary on neuroethics,[7] Nature asked its readers about their experiences with cognitive enhancement. Twenty percent of those who answered had used medication, mostly Ritalin or Provigil, without a diagnosed condition to enhance their concentration, memory, or problem-solving (another 14 percent used them with a prescription), and about three quarters of the respondents took such drugs once a month or more.[8]

The question of brain-boosting drugs has simmered in medical enclaves since at least 2004, when the American Medical Association’s ethics journal Virtual Mentor featured the topic. The British Medical Association followed suit with a conference and ensuing discussion paper, “Boosting your brainpower: ethical aspects of cognitive enhancements.”[9] The BMA went beyond questions of individual safety, agency, and social inequality to ask if we should invest in creating and testing drugs on healthy people to improve normal performance when illnesses and other disorders require therapy, and if we should encumber doctors with supervising enhancement and handling the fallout when things go wrong, whether from misuse or side-effects like hypertension and altered personalities.

The transformation from a paradigm that corrects impairment to one that enhances normalcy poses a complicated question for policy.

These discussions have remained largely hypothetical. However, some medical students and residents already boost their mental powers by taking drugs off label, which matters since doctors model behaviors for patients and provide legal access to medication. Moreover, the medical community largely polices itself. Thus, the norms of rising doctors will influence whatever regulation of cognitive enhancement, if any, occurs, and any successful regulation must in turn penetrate medical culture, which physicians and physicians-in-training collectively forge in the absence of some laws and in quiet deviation from others.

Almost all the recent or aspiring MDs quoted above agreed cognitive enhancement would spread assuming nothing else changed. A first-year student concluded, similarly to many, “If there’s money to be made, as long as people want that stuff, then there’ll be people interested in supplying it.” And demand exists. “If there’s a pill out there that can’t be abused,” explained the neurology resident, “but makes me more alert and a better doctor during the day and gives me energy to work out at the gym afterward, sure, I’d take it.” One MD-Ph.D. heard people contemplating nicotine patches or gum to study longer.

The potential for abuse, however, is key. Residents, like any doctor, can prescribe many if not all drugs, and they do so in what several called a “gray zone” between the letter of the law and tacit communal standards. Most states prohibit prescribing drugs outside a formal patient-physician relationship except in extreme cases. Yet at least three of the residents I spoke with bend that law and remain firmly within their group norms. According to the neurologist, “If I have a cold that I think needs an antibiotic, then I get a colleague to write the prescription. It’s not 100 percent right, but I do it out of convenience. But for narcotics or stimulants or anything that would raise eyebrows, I wouldn’t.” The MD-Ph.D. said, “There are some fairly benign medicines that most medical professionals would say writing an Rx for a friend wouldn’t be a big deal.  And then there are the psych, pain, sleeping drugs that writing for anyone would raise eyebrows.” Another resident illustrated the gray zone: “All 3 of these [different prescriptions for family] would have flown under the radar and I used my clinical judgment to decide that they were or were not okay.”

If cognitive enhancement establishes itself among medical professionals, then “under the radar” and not yet “raising eyebrows” may annex stimulants like methylphenidate. An effective policy on cognitive enhancement, therefore, should reach this gray zone, which may require education and other ways to change medical culture, since medical cultural norms do not always coincide neatly with the law. Indeed, two studies indicate people who conduct themselves unprofessionally during medical training are significantly more likely to be disciplined by state medical boards later, but unprofessionalism is in the eye of beholding supervisors, deans, and board certification scores.[10] That discretion muddles whether discipline for inappropriate prescription and acquisition of drugs—which constitute 5 to 8 percent of violations in these studies—is uncommon because these incidents are rare or because only cases too far beyond the community’s pale are punished.

Dr. Gary Carr, president-elect of the Federation of State Physician Health Programs, believes “Education, education, education” can best translate any professional guidelines about cognitive enhancement into practice. Although he has yet to see data that demonstrate cognitive enhancement needs to be addressed among medical residents and students, he considers it “a slippery slope” from taking someone else’s Ritalin to trying amphetamines or cocaine. Furthermore, prescribing Ritalin or Provigil “without just cause” could incur “board action for practicing ‘outside the scope.’” Dr. Carr thinks physician health programs could address cognitive enhancement, if needed, since “most of us have some opportunity to lecture to the students/residents,” and the programs take referrals and provide treatment.

Yet physician health programs were created to prevent physician impairment, typically from alcohol and drug abuse, not physician enhancement. AMA ethics, too, emphasize physician impairment. Hence, just as a society’s shift from therapy to enhancement outstrips defined policy, detecting physician enhancement under the rubric of physician impairment appears difficult. Most medical students and residents are referred for poor performance to a physician health program. Improved performance would fly under the radar; only a secondary effect would register, such as the ethical impairment of forging a prescription or perhaps making a mistake in treatment when the cognitive enhancer wore off or misfired, such as increasing impulsive decision making.

The transformation from a paradigm that corrects impairment to one that enhances normalcy poses a complicated question for policy. In the interim, practices continue to develop. As one recent MD said, “My personal belief is, you can drink, smoke, medicate as much as you want as long as it does not impair your personal or professional life.” She may be right—for now.

Mark Meier is a freelance writer with a particular interest in ethics, identity, and social structure.

Notes

[1] Laura K. Barger, et al. 2006, “Impacts of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures,” PLoS Medicine 3 (12), e487 doi:10.1371/journal.pmed.0030487. Current ACGME regulations limit shifts to 30 consecutive hours, with 10 hours off in between, and no more than 80 hours average per week over any four-week period. Some exceptions are allowed, and violations do occur.

[2] Amy M. Fahrenkopf, et al., “Rates of medication errors among depressed and burnt out residents: prospective cohort study,” British Medical Journal (2008), doi: 10.1136/bmj.39469.763218.BE

[3] “International Narcotics Control Board 1999 Annual Report,” available at http://www.incb.org/incb/annual_report.html.

[4] The results of these and other small clinical trials are summarized in the British Medical Association’s discussion paper, “Boosting your brainpower: ethical aspects of cognitive enhancements” from November 2007, available at http://www.bma.org.uk/ap.nsf/content/CognitiveEnhancement2007.

[5] T.E. Wilens, et al, “Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature,” Journal of the American Academy of Child and Adolescent Psychiatry 47 (1) (2008): 21-31.

[6] Ibid.

[7] Barbara Sahakian and Sharon Morein-Zamir, “Professor’s little helper,” Nature 450 (2007): 1157-59.

[8] The full survey results are available at http://network.nature.com/forums/naturenewsandopinion/1309.

[9] The August 2004 issue of Virtual Mentor (virtualmentor.ama-assn.org) included Martha Farrah’s “Neuroethics,” Abe Schwabe’s “Ethical Issues in the Application and Prescription of CNS Interventions,” and Anjan Chatterjee’s “Cosmetic Neurology: For Physicians the Future is Now”; the same journal in its February 2007 issue printed Steffen K. Rosahl’s “Neuroprosthetics and Neuroenhancement: Can We Draw a Line?” The New England Journal of Medicine in September 15, 2005, published an essay by Richard Kadison of Harvard’s Health Services, “Getting an Edge—Use of Stimulants and Antidepressants in College,” and in November 2007, the BMA released its discussion paper. A month later, Nature published the commentary which led to its informal survey of readers, a story The New York Times picked up in Benedict Carey’s “Brain Enhancement Is Wrong, Right?’ from March 9, 2008.

[10] Maxine Papadakis, et al., “Disciplinary Action by Medical Boards and Prior Behavior in Medical School,” New England Journal of Medicine 353 (25) (2005): 2673-83. Maxine Papadakis, et al., “Performance during Internal Medicine Residency Training and Subsequent Disciplinary Action by State Licensing Boards,” Annals of Internal Medicine 148 (11) (2008): 869-76.

Tags: bioethics, enhancement, medicine

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