Line Between Healer and Pusher Is Getting Thin

There used to be a time when people went to health care practitioners to help with a perceived illness but increasingly the siren songs of “better than well” are changing the boundaries between healing and enhancing. Hence, I ask the rhetorical question: And at what point does a physician become a drug pusher?

Here is a link to an article in Psychiatric Times that wrestles with this issue:

Should Psychiatrists Prescribe Neuroenhancers for Mentally Healthy Patients?

by Cynthia M. A. Geppert, MD, PhD, MPH and Peter J. Taylor, DO, MA

“In 2009, the Ethics, Law and Humanities Committee of the American Academy of Neurology (AAN) issued guidance regarding responding to requests from adult patients for neuroenhancers.1 The AAN report defines this term as “prescribing medications to normal adults for the purpose of augmenting their normal cognitive or affective function.” The author, Cynthia Geppert, has previously summarized the content of the AAN paper in aPsychiatric Times podcast available at http://www. psychiatrictimes.com/podcasts.

Recent articles in both The New Yorker2 and Nature3 confirm the widespread use of cognitive enhancers, especially among students and academics. Prevalence is a pragmatic but not necessarily an ethical argument. The most controversial aspect of the guidance is its underlying assumption that a valid goal of medicine is to improve the executive function of individuals who have no “diagnosable mental health or medical condition.”

There has been considerable commentary on the topic of the report in the neurology journals and bio-ethics blogs—most of it favorable—although there have been some essays of caution.4-7 There has been surprising little discussion in the psychiatric community, where a broad and morally serious dialogue on the subject of cosmetic psychopharmacology has not occurred since Peter Kramer’s prescient Listening to Prozac.8 The one notable exception is a Medscape news report on a presentation Derryck Smith, MD, made at the 60th Annual Conference of the Canadian Psychiatric Asso-ciation in September 2010.5

Since patients are already taking these medications, and we as psychiatrists are familiar with the utility of the drugs for clinical indications, Smith argues that it would be in the best interest of patients if psychiatrists prescribed neuroenhancers in a medical setting. The article quotes Smith as saying, “I am absolutely fascinated that the neurologists are in this game before psychiatrists. Psychiatry should be at the forefront of this because these are all medications that we use on a regular basis.” He refers to the guidance of the AAN as supporting the safety, ethics, and reasonableness of prescribing these medications if they will benefit patients. He concludes, “So psychiatrists are at liberty to use these medications as they see fit with fully informed patients.”

In this article, we present a counterpoint to Dr Smith’s position, and indeed to the application of the AAN guidance to psychiatry. We argue on the basis of core concepts in psychiatric ethics that psychiatrists should not at this time prescribe neuroenhancing medications for patients who lack clinical indications for these drugs…”

There is much more at the link, though you’ll have to register for a free subscription:

Should Psychiatrists Prescribe Neuroenhancers for Mentally Healthy Patients?

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