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Ethically Justified, Clinically Applicable Criteria for Physician Decision-Making in Psychopharmacological Enhancement

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Abstract

Advances in psychopharmacology raise the prospects of enhancing neurocognitive functions of humans by improving attention, memory, or mood. While general ethical reflections on psychopharmacological enhancement have been increasingly published in the last years, ethical criteria characterizing physicians’ role in neurocognitive enhancement and guiding their decision-making still remain highly unclear. Here it will be argued that also in the medical domain the use of cognition-enhancing drugs is not intrinsically unethical and that, in fact, physicians should assume an important role in gating their usage. For finding normative orientation, concepts of disease, normality or medicine will not be helpful since—due to their cryptonormative nature—they rather hamper than allow targeted discussion and decision-making. As an alternative, the common and widely accepted bioethical criteria of beneficence, non-maleficence, autonomy and distributive justice allow a clinically applicable, highly differentiated context- and case-sensitive approach. By embedding decision-making in a participative physician–patient relationship extrinsic objections against neurocognitive enhancement (e.g. invalid perceptions about efficacy, benefit or risk; questionable voluntariness; restrained decision-making capacity) can be curtailed.

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Notes

  1. This thesis does of course not imply that there are no fundamental ethical principles which would apply to all contexts or that different contexts would always entail fundamental differences in the content and applicability of moral judgments. Nor does it endorse a dichotomous ethical assessment of either the methods or the goals. For example, also in science we have to ethically judge the methods employed (and not only the results) and disapprove them if they do not comply with certain fundamental ethical standards, e.g. we may use the results of Nazi medicine but strongly disapprove its practice. The thesis only claims that some contexts might differ in their normative judgements about which methods are justified and which are not and in their gradual extent in which they primarily value the method or the result.

  2. This example shows that I do not want to defend the ambitions claim that values might be relative. Rather, I claim that when evaluating neuroenhancement measures one has to look—inter alia—at the different purposes of the respective domain: Students are being asked to learn material, air traffic controllers are being asked to perform. If the purpose of college education was not to learn, but to perform, we might even approve of the use of enhancers in that context.

  3. As, for example, claimed by Sandel [13] where he stipulates that the moral concepts and criteria which we usually use in bioethics are insufficient to adress the ethical questions in the enhancement debate.

  4. An additional basic ethical principle requires that the invested resources should be distributed in a just way (principle of justice). Since this principle requires a systematically separate analysis of physician’s role in resource allocation and of each state’s practice of health care spending and reimbursement, I will not pay much attention to the last principle for now and presuppose that some form of financing is agreed upon, most probably some form of private payment. It should only be pointed out that even if access to cognition-enhancing drugs was distributed unequally, this fact could not serve as a straight-forward argument to reject neurocognitive enhancement outright. Currently, access to potentially body enhancing dietary supplements like vitamins or creatine or to cognition-enhancing substances like energy drinks does in fact primarily depend on one’s willingness and capacity to buy these substances, but none of these substances has raised ethical concern so far for violating the principle of distributive justice. The same applies to education, as pointed out by Martha Farah: “Education is a cognitive enhancer that is very inequitably distributed, but society is not against education. Conversely, neurocognitive enhancers might be relatively easy to distribute widely” [32]. Likewise, nobody concludes that, for example, technologies that enhance eyesight, e.g. spectacles, are unethically because the are not accessible all over the world and for all societal strata [33]. Even if there were some serious problems of unequal access and distribution of neuroenhancement means, this would not present an intrinsic counter-argument against neuroenhancement, leading to e.g. a disapproval of neurenhancement per se, but only present an extrinsic argument, leading to questioning practices of access and distribution of neuroenhancement. Then, however, the crucial question is not whether doctors should regulate neuroenhancement or not, but how we can create a fair access and distribution of neuroenhancement means. This question can and should not be answered on (the micro-)level of physician-patient decision making, but requires an extensive analysis of regulation practices on macro-levels of allocation which cannot be part of this paper.

  5. A roughly analogous form of justification for such a kind of “minimal paternalism” is given by DeGrazia for another ethical context in [53]. According to the principle of minimal paternalism it is justified to override a person’s substantially autonomous decision-making for that person’s benefit, if (a) there is substantial evidence that otherwise he or she will be in extremely grave danger, (b) such overriding offers a reasonable prospect of success (that is, of bringing about a relative net benefit to the person) and (c) such overriding is the least restrictive known to achieve the desired protection (p. 222).

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Acknowledgement

I thank the anonymous reviewers for their valuable comments and the “European platform” of the Volkswagen foundation for their financial support.

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  1. Department for Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany

    Matthis Synofzik

  2. Department of Medical Ethics, University of Tübingen, Tübingen, Germany

    Matthis Synofzik

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Synofzik, M. Ethically Justified, Clinically Applicable Criteria for Physician Decision-Making in Psychopharmacological Enhancement. Neuroethics 2, 89–102 (2009). https://doi.org/10.1007/s12152-008-9029-1

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