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The Neurocognitive Enhancement of Surgeons: An Ethical Perspective
Journal of Surgical Research 152, 167–172 (2009) doi:10.1016/j.jss.2007.12.761
RESEARCH REVIEW The Neurocognitive Enhancement of Surgeons: An Ethical Perspective Oliver J. Warren, M.R.C.S. (Eng),1 Daniel R. Leff, M.R.C.S. (Eng), Thanos Athanasiou, Ph.D., F.E.T.C.S., Christopher Kennard, F.Med.Sci., F.R.C.P., and Ara Darzi, F.A.C.S., F.R.Eng (Hon), F.Med.Sci, K.B.E. Surgical Cognition and Neuro-Imaging Group, Department of BioSurgery and Surgical Technology, Imperial College London, St. Mary’s Hospital, London, United Kingdom Submitted for publication August 6, 2007
Neurocognitive enhancement is a rapidly expanding scientific field. The vast ethical implications of this developing field for surgical practice have yet to be considered within the literature. This article outlines the reasons surgeons may, in the near future, consider using neurocognitive enhancement and addresses the resulting significant ethical implications of this. We do not seek to support or denounce the potential role of neurocognitive enhancement in surgeons, but to stimulate a debate, which, with ever-increasing levels of stimulant use in schools and colleges, and with a pharmaceutical industry driving the creation of new neuroactive products, has now become a necessity. © 2009 Elsevier Inc. All rights reserved.
Key Words: ethics; cognition; psychopharmacology; surgery. INTRODUCTION
Neurocognitive enhancement, the practice of improving the neurological function of individuals who are disease free, has been the subject of recent media, political, and ethical interest [1–3]. Nonpharmacological methods, such as Transcranial Magnetic Stimulation, Brain–Machine interfaces, and neurosurgical implantation of devices and tissue are all at early stages of development, with most research still focused on their role alleviating pathology [4 –7]. Psychopharmacological enhancement is further developed and has undergone more extensive evaluation. Prescription medications such as donepezil (Aricept; Eisai, Tokyo, Japan), modafinil (Provigil; Cephalon Inc., Frazer, PA), methylphenidate (Ritalin; Novartis, Bern, Switzerland), and bromocriptine (Parlodel; Novartis), originally developed to treat neurological and psychiatric illnesses, are be1
To whom correspondence and reprint requests should be addressed at Department of BioSurgery and Surgical Technology, Imperial College, London, 10th Floor QEQM Building, St. Mary’s Hospital, London, W2 1NY, United Kingdom. E-mail: [email protected].
ing increasingly investigated for their potential to enhance memory, cognition, and executive function in healthy individuals. While this may sound radical, for many healthy people enhancing normal neurocognitive function is already a fact of life. In the United States the proportion of boys taking methylphenidate is at epidemic levels, exceeding the highest estimated prevalence of Attention Deficit Hyperactivity Disorder [8], which suggests that normal childhood high spirits are being dampened by pharmacological means to enhance the educational experience. This is not limited to schools; an estimated 16% of students at some United States universities take prescription medication as study aids [9]. Finally, nonprescription supplements are being increasingly used in an attempt to improve memory, cognition, and ward off fatigue. Ginkgo biloba, a Chinese herbal medicine, is now a billion dollar industry in the United States alone [10], despite only limited effects on cognition [11]. The field of neurocognitive enhancement is already here and is growing. The vast ethical implications of this developing field have been partly addressed within the literature, but from the view of prescriber [12] or society as a whole [13]; no one has considered the implications of neurocognitive enhancement for current surgical practice. This article outlines why surgeons may soon consider using prescription medications, or technological interventions, originally designed to treat neuropsychological pathologies, to enhance their performance. We focus predominantly on drugs, as the evidence suggests this is the more imminent and likely form of neurocognitive enhancement that surgeons may consider, and address the resulting significant ethical implications of these actions. We do not seek to support nor denounce the potential for neurocognitive enhancement in surgeons, simply to outline the ethical debate that now needs to take place.
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WHAT ARE THE POTENTIAL TARGETS FOR NEUROCOGNITIVE ENHANCEMENT IN SURGEONS?
There is an increasing array of pharmacological agents that have been demonstrated to affect “Executive Function,” the abilities that enable flexible, taskappropriate responses in the face of irrelevant competing inputs or more habitual but inappropriate response patterns [13]. This includes cognition, working memory, and attention, important functions for surgeons. Methylphenidate (Ritalin) is already prescribed to sufferers of attention-deficit hyperactivity disorder (ADHD) to improve attention, concentration, spatial working memory, and planning [14, 15]. However, in one study, healthy volunteers performed a novel neuropsychological test of planning more accurately after being given methylphenidate than after being given a placebo [16]. Similarly startling results in healthy subjects have been shown elsewhere [17, 18]; bromocriptine can have beneficial effects on visual–spatial working memory functions (an integral part of surgical practice) in normal human subjects [17]. Five milligrams of donepezil (a cholinesterase inhibitor used in the treatment of Alzheimer’s disease) was administered daily for 1 month to healthy middle-aged pilots in training, a group not dissimilar to surgeons in their reliance on both cognitive and motor skills. The treatment group had significantly better posttraining retention of complex aviation tasks, particularly when responding to emergencies [18]. Finally, modafinil, one of the newest potential neurocognitive enhancers, has been investigated for its alleged ability to alleviate the impairment and symptoms associated with fatigue. Modafinil has been shown to sustain alertness, reduce “Ratings of Perceived Exhaustion,” and ameliorate the cognitive impairments that occur as a function of sleep deprivation, particularly those relating to attention and reaction time [19 –21]. The military have performed their own studies, showing modafinil to improve helicopter pilot performance on simulators at the combined nadir of sleep deprivation and circadian troughs [22]. Modafinil has been compared to other stimulants, such as dexamphetamine [23, 24], and appears equally effective at maintaining cognitive function during sleep deprivation. Importantly, it seems to allow sleep to occur when the opportunity arises [25]. More controversially, these findings led one group to investigate if modafinil may improve executive function in rested healthy young adults. Randall et al. performed a meta-analysis of their own work [26, 27] and found modafinil to significantly improve cognitive performance, particularly in tests of vigilance and cognitive speed [28]. Despite legislation being introduced in both Europe [29] and the United States [30] to limit working hours, fatigue remains a problem [31–33]. Traditionally, surgeons have relied on napping or drinking coffee or tea
(stimulants of natural origin), but caffeine is not the perfect solution, causing tachycardia and worsening tremor, both of which have implications for surgeons involved in fine-motor performance [34]. The prospect of fatigued surgeons taking a prescription drug, such as modafinil, to allow them to operate for longer, and possibly to a higher standard, is perhaps not as farfetched as some may suggest. This drug has already been trialed in emergency physicians, when performing non-medical-related tasks at the end of a nightshift [35]. The study had self-reported failings and thus did little to clarify modafinil’s potential role, but nevertheless it was the first to consider the prospect that clinicians could use medication to enhance their performance. Undoubtedly, neurocognitive enhancement raises deep and contentious ethical dilemmas, but when considered in clinicians, especially surgeons, these ethical dilemmas take on an even more complex dimension, as they are responsible for the safety and wellbeing of others; their actions have consequences not only for themselves but also for their patients. As initial research begins, and media reports of off-label use grow, the surgical community would benefit from a comprehensive debate regarding the ethical dilemmas that arise when considering the use of neurocognitive enhancement by surgeons. ETHICAL CONSIDERATIONS
We explore the ethical implications of neurocognitive enhancement of surgeons by considering the key areas summarized in Fig. 1. SAFETY
When considering the potential risks involved in neurocognitive enhancement, it is essential to define the scale of intervention being discussed. While anything may become possible in the future, we find it hard to imagine surgeons considering invasive neurosurgical procedures to insert neural implants, just to gain a slight increase in capability. However, taking medication, either regularly or when needed, seems more plausible. We are aware that all medicines have side effects, from minor inconvenience to major morbidity, but as clinicians we make risk– benefit decisions every time we prescribe. Often the decision is straightforward; the benefits of prescribing antibiotics to a patient with pneumonia outweigh the risks of them developing pseudomembranous colitis. The pendulum swings however when considering the administration of drugs to healthy individuals; greater benefits and/or diminishing risks are required to ensure that any intervention, even in the informed individual, remains justified. On occasions the balance may be perfectly obvious—a surgeon who drinks coffee in the morning to
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FIG. 1.
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The ethical considerations arising from the potential neurocognitive enhancement of surgeons.
be more alert and productive is likely willing to accept a slight tachycardia and mild tremor. However, other side effects may be less acceptable, because the risk to the surgeon or patient is higher. Modafinil can cause gastrointestinal upset, anxiety, hypertension, and tachycardia [36 –39]. Traditional stimulants such as methylphenidate have a significant risk of dependence [40], and while there is little evidence to suggest modafinil might cause dependence, even in individuals with a history of addiction to cocaine [41, 42], concerns must arise that surgeons who choose to enhance in any fashion might develop dependence, physical or emotional, to the drug in question. Furthermore, many of these novel drugs, and other interventions, have predominantly been tested in young males, a demographic unrepresentative of all surgeons. The safety and efficacy of neurocognitive enhancement could well differ between surgeons, depending on their age and gender. Finally, we must consider what long-term problems regular neuroactive medication and other forms of neuromanipulation might cause. Our knowledge in this area is minimal and will likely remain so for a significant time yet. It is not only the surgeon’s wellbeing we should consider but that of the patient. Drugs known to manipulate behavior might have unpredictable results in practicing clinicians, placing the patient at risk. Dexamphetamine, a stimulant used on occasions by the United States military, is effective at eradicating fatigue but may cause overconfidence [43], an undesirable quality in any surgeon making management decisions under stressful circumstances. Subtle behavioral changes,
not manifest in the majority of trial participants, may be brought to the fore by the significant stress surgeons can be placed under within their workplace. In the end, the key when discussing the safety of any intervention will always be the risk– benefit ratio; relatively minor risks to surgeons may be acceptable if they safeguard patient care. The concept of surgeons risking their health to benefit patients is not an alien one; it occurs every time we operate on patients with blood-borne transmissible diseases, because the risk is felt justifiable to improve the patients’ chances of recovery, and steps are taken to minimize that risk. However, at what point is the cumulative knowledge regarding any intervention deemed weighty enough to allow its use? This question is difficult enough when considering standard interventions, where both beneficial and adverse outcomes affect the same individual. What makes this ethical discussion much more complex is that if a significant improvement in the performance of a surgeon can be demonstrated following an intervention, potential benefits are passed to others, while any risk remains with the individual who has been enhanced. FREEDOM OF CHOICE
Both the United Kingdom and the United States are strongly libertarian, and many people will believe that if individuals are given adequate information about effects, and potential side effects, they should be free to make their own decisions. Should surgeons not be free to take medication because they feel it improves their
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technical and cognitive performance, even if they put themselves at a slight risk of adverse events? If we demonstrably improve a surgeon’s performance, and the surgeon is aware of this, would they be compelled by their own moral standards to continue, to maintain their level of ability? While individual freedoms are important, any civil liberty must be balanced against safeguarding the public good. Surgeons are regulated in both the United States and the United Kingdom and are not free to behave in any manner they choose if it has a substantial probability of harming patients. Being under the influence of alcohol or illicit drugs at work leads to suspension, investigation, and likely dismissal, and rightly so. If a neuroactive intervention is found on occasions to be significantly detrimental to performance, so it must be prohibited. We suggest that the most important thing is that as innovations arise they are scientifically, ethically, and economically evaluated to allow as much information as possible to be available to the surgical community.
sonhood and alters what it means to be “human” [12]. If surgeons choose to take medication, are they becoming slaves to their jobs, entering into a Faustian pact where they are willing to put their performance in the workplace ahead of their own sense of personhood, possibly to the detriment of their health? Perhaps, but for some medicine paves the way of revealing an identity that is otherwise hidden by circumstance. People claim to “find themselves” through steroids, antidepressants, mind-altering drugs, and amphetamines [45]. Major surgical procedures from breast enlargement therapy to gender reassignment operations are used to make individuals feel more like the person they wish to be. Beyond medicine, others have practiced what they see as self-improvement through more “natural” methods, such as formal religion, spiritualism, and travel. While none of these things would lead us to advocate neurocognitive enhancement per se, they serve as examples that altering ones mind, body, or personality is not always regarded negatively by society.
CHARACTER, INDIVIDUALITY, AND PERSONHOOD DISTRIBUTIVE JUSTICE
Within medical society, there is a “no pain, no gain” belief system, a belief that toil, struggle, and sacrifice are necessary for progression, and that hard work throughout the undergraduate and postgraduate years builds character. The ethical argument that follows is that “unnatural interventions” that ease the acquisition and retention of skill and knowledge undermine good character. Improving without working is cheating, and cheating cheapens us all [44]. These are valid concerns but in recent years numerous technical advances have come about which make both the acquisition and the performance of the knowledge and skills of surgery easier. We may admire the dedication and toil previously required to create a thesis using a typewriter, perform longhand data analysis, or care for patients without automated investigations and imaging, but no one seriously suggests that we work without those innovations that have now made our lives easier. Most of us buy books, go on courses, and seek tutoring to improve our knowledge and skill levels. Many of us will have used legal drugs, such as nicotine or alcohol as stress relievers, or relied upon caffeine to allow longer working hours or study periods. All of these are neurologically active compounds, which help us tackle life’s challenges, and although they may make life “easier,” they are not commonly regarded as character eroding. Will neurocognitive enhancement simply become the next in a long line of advances that help us acquire new skills more rapidly, retain knowledge longer, or fight off the normal human emotions of tiredness and anxiety? Some authors have suggested that attempting to alter the brain, be it with drugs, invasive procedures, or magnetic stimulation threatens our notion of per-
If neurocognitive enhancers are not fairly distributed, they will provide an unfair advantage only for the rich or well connected. This may be particularly true at medical schools, where relatively wealthy undergraduates already tend to have certain advantages over their poorer colleagues; are we to add to these by making neurocognitive enhancement a preserve of the wealthy? Conversely, our society is full of inequality already and it may be no more grounds for prohibiting access to enhancement than it is to other forms of cognitive assistance, such as continuing education and computerized decision support [46]. Psychoactive drugs may be easier to distribute equitably than other forms of “unfair advantage.” Furthermore, enhancers may narrow the gap between borderline students and those who excel, reducing performance variation [28]. COERCION AND REGULATION
If robust evidence demonstrating significant performance improvement following neurocognitive enhancement was forthcoming, surgeons may feel pressure from society to participate. It may go against certain medical principles to envisage coercion of an individual to take any drug, but this is not without similar precedents. Many societies strongly encourage participation in vaccination programs, on the advice of its physicians. Likewise it pressures (or forces via legislation) its clinicians to incorporate certain practices into medicine that are known to be key to good outcomes, e.g., hand washing and sterility prior to and during surgery. These are useful and warranted forms of coercion. What will our employers feel about a drug that makes
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us less prone to error, able to work longer hours, or to operate more efficiently? Employers are able to request certain behavioral standards from their employees, dictate rest periods, and insist on abstinence from certain drugs to ensure that their doctors perform well— will a day arise where they can recommend or even insist on surgeons’ being artificially enhanced? This may seem fanciful, but recent work has suggested that a mixture of napping and caffeine attenuates fatigue in interns and thus should be adopted by hospital administration [47, 48]. Why not other types of stimulant? Will the public want treatment by surgeons under the influence of neuroactive medication? As patient awareness of variations in standards increases, so they and their families may enquire as to whether or not we are using a specific enhancer and may encourage or discourage this practice as they see fit. Furthermore, coercion is not always explicit. Surgeons are inherently competitive and in healthcare markets increasingly defined by provider competition, competing against enhanced colleagues may act as an incentive to enhance oneself. Internal pressures to perform at the highest level, while working long hours and undertaking international travel, is already leading academic clinicians to use neurocognitive stimulants [49]. How would we feel if a colleague outperformed us in a postgraduate examination, then subsequently revealed they had been taking modafinil at the time? Or had taken donepezil while preparing for their examination? Would this not at least make us consider doing the same? How as surgeons are we to deal with these competing pressures? What can we tell patients, colleagues, or employers if they enquire? As long as professional standards and legislation pertaining to prescription are not broken, there is currently nothing illegal in taking neuroactive medication. There are no existing guidelines to reference from our colleges or professional associations. We do not even know how many surgeons are occasionally or regularly using this sort of medication to affect their performance. Much research is required to inform our opinions in this area, along with subsequent ethical discussion. If guidelines or legislation is created, they should help, inform, and reassure both patients and surgeons and must involve our academic and representative bodies, the public, health providers, and experts in the area.
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RESEARCH REVIEW The Neurocognitive Enhancement of Surgeons: An Ethical Perspective Oliver J. Warren, M.R.C.S. (Eng),1 Daniel R. Leff, M.R.C.S. (Eng), Thanos Athanasiou, Ph.D., F.E.T.C.S., Christopher Kennard, F.Med.Sci., F.R.C.P., and Ara Darzi, F.A.C.S., F.R.Eng (Hon), F.Med.Sci, K.B.E. Surgical Cognition and Neuro-Imaging Group, Department of BioSurgery and Surgical Technology, Imperial College London, St. Mary’s Hospital, London, United Kingdom Submitted for publication August 6, 2007
Neurocognitive enhancement is a rapidly expanding scientific field. The vast ethical implications of this developing field for surgical practice have yet to be considered within the literature. This article outlines the reasons surgeons may, in the near future, consider using neurocognitive enhancement and addresses the resulting significant ethical implications of this. We do not seek to support or denounce the potential role of neurocognitive enhancement in surgeons, but to stimulate a debate, which, with ever-increasing levels of stimulant use in schools and colleges, and with a pharmaceutical industry driving the creation of new neuroactive products, has now become a necessity. © 2009 Elsevier Inc. All rights reserved.
Key Words: ethics; cognition; psychopharmacology; surgery. INTRODUCTION
Neurocognitive enhancement, the practice of improving the neurological function of individuals who are disease free, has been the subject of recent media, political, and ethical interest [1–3]. Nonpharmacological methods, such as Transcranial Magnetic Stimulation, Brain–Machine interfaces, and neurosurgical implantation of devices and tissue are all at early stages of development, with most research still focused on their role alleviating pathology [4 –7]. Psychopharmacological enhancement is further developed and has undergone more extensive evaluation. Prescription medications such as donepezil (Aricept; Eisai, Tokyo, Japan), modafinil (Provigil; Cephalon Inc., Frazer, PA), methylphenidate (Ritalin; Novartis, Bern, Switzerland), and bromocriptine (Parlodel; Novartis), originally developed to treat neurological and psychiatric illnesses, are be1
To whom correspondence and reprint requests should be addressed at Department of BioSurgery and Surgical Technology, Imperial College, London, 10th Floor QEQM Building, St. Mary’s Hospital, London, W2 1NY, United Kingdom. E-mail: [email protected].
ing increasingly investigated for their potential to enhance memory, cognition, and executive function in healthy individuals. While this may sound radical, for many healthy people enhancing normal neurocognitive function is already a fact of life. In the United States the proportion of boys taking methylphenidate is at epidemic levels, exceeding the highest estimated prevalence of Attention Deficit Hyperactivity Disorder [8], which suggests that normal childhood high spirits are being dampened by pharmacological means to enhance the educational experience. This is not limited to schools; an estimated 16% of students at some United States universities take prescription medication as study aids [9]. Finally, nonprescription supplements are being increasingly used in an attempt to improve memory, cognition, and ward off fatigue. Ginkgo biloba, a Chinese herbal medicine, is now a billion dollar industry in the United States alone [10], despite only limited effects on cognition [11]. The field of neurocognitive enhancement is already here and is growing. The vast ethical implications of this developing field have been partly addressed within the literature, but from the view of prescriber [12] or society as a whole [13]; no one has considered the implications of neurocognitive enhancement for current surgical practice. This article outlines why surgeons may soon consider using prescription medications, or technological interventions, originally designed to treat neuropsychological pathologies, to enhance their performance. We focus predominantly on drugs, as the evidence suggests this is the more imminent and likely form of neurocognitive enhancement that surgeons may consider, and address the resulting significant ethical implications of these actions. We do not seek to support nor denounce the potential for neurocognitive enhancement in surgeons, simply to outline the ethical debate that now needs to take place.
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0022-4804/09 $36.00 © 2009 Elsevier Inc. All rights reserved.
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JOURNAL OF SURGICAL RESEARCH: VOL. 152, NO. 1, MARCH 2009
WHAT ARE THE POTENTIAL TARGETS FOR NEUROCOGNITIVE ENHANCEMENT IN SURGEONS?
There is an increasing array of pharmacological agents that have been demonstrated to affect “Executive Function,” the abilities that enable flexible, taskappropriate responses in the face of irrelevant competing inputs or more habitual but inappropriate response patterns [13]. This includes cognition, working memory, and attention, important functions for surgeons. Methylphenidate (Ritalin) is already prescribed to sufferers of attention-deficit hyperactivity disorder (ADHD) to improve attention, concentration, spatial working memory, and planning [14, 15]. However, in one study, healthy volunteers performed a novel neuropsychological test of planning more accurately after being given methylphenidate than after being given a placebo [16]. Similarly startling results in healthy subjects have been shown elsewhere [17, 18]; bromocriptine can have beneficial effects on visual–spatial working memory functions (an integral part of surgical practice) in normal human subjects [17]. Five milligrams of donepezil (a cholinesterase inhibitor used in the treatment of Alzheimer’s disease) was administered daily for 1 month to healthy middle-aged pilots in training, a group not dissimilar to surgeons in their reliance on both cognitive and motor skills. The treatment group had significantly better posttraining retention of complex aviation tasks, particularly when responding to emergencies [18]. Finally, modafinil, one of the newest potential neurocognitive enhancers, has been investigated for its alleged ability to alleviate the impairment and symptoms associated with fatigue. Modafinil has been shown to sustain alertness, reduce “Ratings of Perceived Exhaustion,” and ameliorate the cognitive impairments that occur as a function of sleep deprivation, particularly those relating to attention and reaction time [19 –21]. The military have performed their own studies, showing modafinil to improve helicopter pilot performance on simulators at the combined nadir of sleep deprivation and circadian troughs [22]. Modafinil has been compared to other stimulants, such as dexamphetamine [23, 24], and appears equally effective at maintaining cognitive function during sleep deprivation. Importantly, it seems to allow sleep to occur when the opportunity arises [25]. More controversially, these findings led one group to investigate if modafinil may improve executive function in rested healthy young adults. Randall et al. performed a meta-analysis of their own work [26, 27] and found modafinil to significantly improve cognitive performance, particularly in tests of vigilance and cognitive speed [28]. Despite legislation being introduced in both Europe [29] and the United States [30] to limit working hours, fatigue remains a problem [31–33]. Traditionally, surgeons have relied on napping or drinking coffee or tea
(stimulants of natural origin), but caffeine is not the perfect solution, causing tachycardia and worsening tremor, both of which have implications for surgeons involved in fine-motor performance [34]. The prospect of fatigued surgeons taking a prescription drug, such as modafinil, to allow them to operate for longer, and possibly to a higher standard, is perhaps not as farfetched as some may suggest. This drug has already been trialed in emergency physicians, when performing non-medical-related tasks at the end of a nightshift [35]. The study had self-reported failings and thus did little to clarify modafinil’s potential role, but nevertheless it was the first to consider the prospect that clinicians could use medication to enhance their performance. Undoubtedly, neurocognitive enhancement raises deep and contentious ethical dilemmas, but when considered in clinicians, especially surgeons, these ethical dilemmas take on an even more complex dimension, as they are responsible for the safety and wellbeing of others; their actions have consequences not only for themselves but also for their patients. As initial research begins, and media reports of off-label use grow, the surgical community would benefit from a comprehensive debate regarding the ethical dilemmas that arise when considering the use of neurocognitive enhancement by surgeons. ETHICAL CONSIDERATIONS
We explore the ethical implications of neurocognitive enhancement of surgeons by considering the key areas summarized in Fig. 1. SAFETY
When considering the potential risks involved in neurocognitive enhancement, it is essential to define the scale of intervention being discussed. While anything may become possible in the future, we find it hard to imagine surgeons considering invasive neurosurgical procedures to insert neural implants, just to gain a slight increase in capability. However, taking medication, either regularly or when needed, seems more plausible. We are aware that all medicines have side effects, from minor inconvenience to major morbidity, but as clinicians we make risk– benefit decisions every time we prescribe. Often the decision is straightforward; the benefits of prescribing antibiotics to a patient with pneumonia outweigh the risks of them developing pseudomembranous colitis. The pendulum swings however when considering the administration of drugs to healthy individuals; greater benefits and/or diminishing risks are required to ensure that any intervention, even in the informed individual, remains justified. On occasions the balance may be perfectly obvious—a surgeon who drinks coffee in the morning to
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FIG. 1.
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The ethical considerations arising from the potential neurocognitive enhancement of surgeons.
be more alert and productive is likely willing to accept a slight tachycardia and mild tremor. However, other side effects may be less acceptable, because the risk to the surgeon or patient is higher. Modafinil can cause gastrointestinal upset, anxiety, hypertension, and tachycardia [36 –39]. Traditional stimulants such as methylphenidate have a significant risk of dependence [40], and while there is little evidence to suggest modafinil might cause dependence, even in individuals with a history of addiction to cocaine [41, 42], concerns must arise that surgeons who choose to enhance in any fashion might develop dependence, physical or emotional, to the drug in question. Furthermore, many of these novel drugs, and other interventions, have predominantly been tested in young males, a demographic unrepresentative of all surgeons. The safety and efficacy of neurocognitive enhancement could well differ between surgeons, depending on their age and gender. Finally, we must consider what long-term problems regular neuroactive medication and other forms of neuromanipulation might cause. Our knowledge in this area is minimal and will likely remain so for a significant time yet. It is not only the surgeon’s wellbeing we should consider but that of the patient. Drugs known to manipulate behavior might have unpredictable results in practicing clinicians, placing the patient at risk. Dexamphetamine, a stimulant used on occasions by the United States military, is effective at eradicating fatigue but may cause overconfidence [43], an undesirable quality in any surgeon making management decisions under stressful circumstances. Subtle behavioral changes,
not manifest in the majority of trial participants, may be brought to the fore by the significant stress surgeons can be placed under within their workplace. In the end, the key when discussing the safety of any intervention will always be the risk– benefit ratio; relatively minor risks to surgeons may be acceptable if they safeguard patient care. The concept of surgeons risking their health to benefit patients is not an alien one; it occurs every time we operate on patients with blood-borne transmissible diseases, because the risk is felt justifiable to improve the patients’ chances of recovery, and steps are taken to minimize that risk. However, at what point is the cumulative knowledge regarding any intervention deemed weighty enough to allow its use? This question is difficult enough when considering standard interventions, where both beneficial and adverse outcomes affect the same individual. What makes this ethical discussion much more complex is that if a significant improvement in the performance of a surgeon can be demonstrated following an intervention, potential benefits are passed to others, while any risk remains with the individual who has been enhanced. FREEDOM OF CHOICE
Both the United Kingdom and the United States are strongly libertarian, and many people will believe that if individuals are given adequate information about effects, and potential side effects, they should be free to make their own decisions. Should surgeons not be free to take medication because they feel it improves their
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technical and cognitive performance, even if they put themselves at a slight risk of adverse events? If we demonstrably improve a surgeon’s performance, and the surgeon is aware of this, would they be compelled by their own moral standards to continue, to maintain their level of ability? While individual freedoms are important, any civil liberty must be balanced against safeguarding the public good. Surgeons are regulated in both the United States and the United Kingdom and are not free to behave in any manner they choose if it has a substantial probability of harming patients. Being under the influence of alcohol or illicit drugs at work leads to suspension, investigation, and likely dismissal, and rightly so. If a neuroactive intervention is found on occasions to be significantly detrimental to performance, so it must be prohibited. We suggest that the most important thing is that as innovations arise they are scientifically, ethically, and economically evaluated to allow as much information as possible to be available to the surgical community.
sonhood and alters what it means to be “human” [12]. If surgeons choose to take medication, are they becoming slaves to their jobs, entering into a Faustian pact where they are willing to put their performance in the workplace ahead of their own sense of personhood, possibly to the detriment of their health? Perhaps, but for some medicine paves the way of revealing an identity that is otherwise hidden by circumstance. People claim to “find themselves” through steroids, antidepressants, mind-altering drugs, and amphetamines [45]. Major surgical procedures from breast enlargement therapy to gender reassignment operations are used to make individuals feel more like the person they wish to be. Beyond medicine, others have practiced what they see as self-improvement through more “natural” methods, such as formal religion, spiritualism, and travel. While none of these things would lead us to advocate neurocognitive enhancement per se, they serve as examples that altering ones mind, body, or personality is not always regarded negatively by society.
CHARACTER, INDIVIDUALITY, AND PERSONHOOD DISTRIBUTIVE JUSTICE
Within medical society, there is a “no pain, no gain” belief system, a belief that toil, struggle, and sacrifice are necessary for progression, and that hard work throughout the undergraduate and postgraduate years builds character. The ethical argument that follows is that “unnatural interventions” that ease the acquisition and retention of skill and knowledge undermine good character. Improving without working is cheating, and cheating cheapens us all [44]. These are valid concerns but in recent years numerous technical advances have come about which make both the acquisition and the performance of the knowledge and skills of surgery easier. We may admire the dedication and toil previously required to create a thesis using a typewriter, perform longhand data analysis, or care for patients without automated investigations and imaging, but no one seriously suggests that we work without those innovations that have now made our lives easier. Most of us buy books, go on courses, and seek tutoring to improve our knowledge and skill levels. Many of us will have used legal drugs, such as nicotine or alcohol as stress relievers, or relied upon caffeine to allow longer working hours or study periods. All of these are neurologically active compounds, which help us tackle life’s challenges, and although they may make life “easier,” they are not commonly regarded as character eroding. Will neurocognitive enhancement simply become the next in a long line of advances that help us acquire new skills more rapidly, retain knowledge longer, or fight off the normal human emotions of tiredness and anxiety? Some authors have suggested that attempting to alter the brain, be it with drugs, invasive procedures, or magnetic stimulation threatens our notion of per-
If neurocognitive enhancers are not fairly distributed, they will provide an unfair advantage only for the rich or well connected. This may be particularly true at medical schools, where relatively wealthy undergraduates already tend to have certain advantages over their poorer colleagues; are we to add to these by making neurocognitive enhancement a preserve of the wealthy? Conversely, our society is full of inequality already and it may be no more grounds for prohibiting access to enhancement than it is to other forms of cognitive assistance, such as continuing education and computerized decision support [46]. Psychoactive drugs may be easier to distribute equitably than other forms of “unfair advantage.” Furthermore, enhancers may narrow the gap between borderline students and those who excel, reducing performance variation [28]. COERCION AND REGULATION
If robust evidence demonstrating significant performance improvement following neurocognitive enhancement was forthcoming, surgeons may feel pressure from society to participate. It may go against certain medical principles to envisage coercion of an individual to take any drug, but this is not without similar precedents. Many societies strongly encourage participation in vaccination programs, on the advice of its physicians. Likewise it pressures (or forces via legislation) its clinicians to incorporate certain practices into medicine that are known to be key to good outcomes, e.g., hand washing and sterility prior to and during surgery. These are useful and warranted forms of coercion. What will our employers feel about a drug that makes
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us less prone to error, able to work longer hours, or to operate more efficiently? Employers are able to request certain behavioral standards from their employees, dictate rest periods, and insist on abstinence from certain drugs to ensure that their doctors perform well— will a day arise where they can recommend or even insist on surgeons’ being artificially enhanced? This may seem fanciful, but recent work has suggested that a mixture of napping and caffeine attenuates fatigue in interns and thus should be adopted by hospital administration [47, 48]. Why not other types of stimulant? Will the public want treatment by surgeons under the influence of neuroactive medication? As patient awareness of variations in standards increases, so they and their families may enquire as to whether or not we are using a specific enhancer and may encourage or discourage this practice as they see fit. Furthermore, coercion is not always explicit. Surgeons are inherently competitive and in healthcare markets increasingly defined by provider competition, competing against enhanced colleagues may act as an incentive to enhance oneself. Internal pressures to perform at the highest level, while working long hours and undertaking international travel, is already leading academic clinicians to use neurocognitive stimulants [49]. How would we feel if a colleague outperformed us in a postgraduate examination, then subsequently revealed they had been taking modafinil at the time? Or had taken donepezil while preparing for their examination? Would this not at least make us consider doing the same? How as surgeons are we to deal with these competing pressures? What can we tell patients, colleagues, or employers if they enquire? As long as professional standards and legislation pertaining to prescription are not broken, there is currently nothing illegal in taking neuroactive medication. There are no existing guidelines to reference from our colleges or professional associations. We do not even know how many surgeons are occasionally or regularly using this sort of medication to affect their performance. Much research is required to inform our opinions in this area, along with subsequent ethical discussion. If guidelines or legislation is created, they should help, inform, and reassure both patients and surgeons and must involve our academic and representative bodies, the public, health providers, and experts in the area.
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