All physicians strive to improve the quality of life in persons who are sick, but to what extent should they help those who are healthy? More neurologists may be facing this dilemma as advances in cognitive neuroscience and neuropharmacology have created new ways to manipulate and improve our cognitive, motor, and affective systems. But such advances have also raised a number of questions: How will so-called life enhancement therapies in healthy persons affect the future of neurology practice? How effective are they? What are the ethical implications? How should neurologists respond to patients who want such drugs and treatments?

According to Anjan Chatterjee, MD, “This distinction between treating disease and improving quality of life is echoed in discussions of therapy versus enhancement. Therapy is treating disease, whereas enhancement is improving normal abilities. Most people would probably agree that therapy is desirable. By contrast, enhancing normal abilities gives pause to many.” Dr. Chatterjee, Associate Professor of Neurology at the University of Pennsylvania in Philadelphia, offered his view on the topic in the September 28 issue of Neurology.

The ways in which people may try to improve the quality of their lives with assistance from the medical community range far beyond Botox. For example, amphetamines might be used to enhance one’s performance during a skilled motor learning task, such as playing the piano or swimming. Transcranial magnetic stimulation could be applied to people who simply do not feel their best. Nervous public speakers can take beta-blockers to reduce anxiety, and neurology residents could use modafinil, a psychostimulant, to stay alert on long shifts.

BETTER BRAINS AND BETTER MEMORIES

For Dr. Chatterjee, one of the most intriguing issues may be the ability to manipulate memories. The idea involves blunting the emotional impact of negative memories, “which most people think would be desirable under certain circumstances, such as soldiers returning from Iraq and Afghanistan,” Dr. Chatterjee said in an interview with Neurology Reviews. “A proportion of them are going to have posttraumatic stress disorder and be dysfunctional. So in that situation, most people would agree that it would be good to have medications that might minimize the effects of such trauma. But it does raise questions as to whether the same or similar medications could be used for perhaps more mundane kinds of traumatic events. Many people have the sense that who we are is the sum of both our pleasurable and painful experiences. If you can start clipping away the painful ones, what does that do to who we are?”

Pitman et al explored the issue of blunting memories and found that patients who were given propranolol after a traumatic event had a reduction in subsequent posttraumatic symptoms. “So it’s not that they don’t remember the actual events of the accident,” explained Dr. Chatterjee. “It’s that the kind of emotional overtones that the event has, or presumably had when it occurred, had been minimized. That seems like a reasonable thing to do. Then the question is, What are the boundary conditions for such interventions? For most people, Thanksgiving is a wonderful holiday. For [others], being around family can be quite stressful. Do you take a little propranolol with your turkey so that later on you are not as distressed?”

In another trial, Yesavage and colleagues found that pilots who took donepezil performed better under emergency conditions in a complex simulator task than did those who took placebo. Overall, however, researchers have a lot to learn regarding how effective many medications would be in people who would be considered “normal,” or healthy, noted Dr. Chatterjee. “We don’t know if the boost would be the same, or less, or even different, for that matter. For example, for the use of drugs like methylphenidate—which is often used quite widely on college campuses—we don’t really know in normal people the extent to which this would improve concentration and learning abilities. It may be the case that there are some groups of people in whom it does help and others in whom it doesn’t.”

A number of medications targeting memory modulation are currently being investigated, such as cyclic adenosine monophosphate response element binding protein modulators and ampakines, noted Dr. Chatterjee. “The idea is that they are working intracellularly to promote the kind of neuronal structural change that accompanies new learning and memory. But there’s nothing about those mechanisms that are being modulated that has anything directly to do with pathology. These are normal mechanisms and not something that’s necessarily been disrupted in the setting of Alzheimer’s disease or some other kind of dementing illness. So now you have treatments or pharmacologic interventions that are really aimed at what essentially is the normal cellular machinery to try and boost it in certain directions.”

THE ROLE OF THE NEUROLOGIST

One of Dr. Chatterjee’s concerns is that life-enhancement treatments could become part of a neurologist’s regular practice. “The role of some neurologists is likely to change,” he said. “I do think current practices push physicians to have less personal involvement with their patients in the sense that reimbursements are largely determined by how you chart your information and what tests you order rather than by how much time you spend trying to get to know someone. There aren’t financial incentives to really get to know people. Making these kinds of quality-of-life decisions to some extent is predicated on having some knowledge, more than superficial knowledge, of who your patient is. So, the one concern is that neurologists may end up having a menu of options and letting the patients or consumers decide what they want. I think most neurologists would feel uncomfortable with that right now, but these things happen in increments. I’m hoping that this will at least get people to start to think before these situations arrive at their doorstep.”

Another problem, said Dr. Chatterjee, is the “competitive winner-take-all environment in which we live and that there’s this push, at least in certain segments of our population, to make sure you get every possible advantage you can—whether you want your kids to get into the best colleges, and so on and so forth. I think this sort of cultural zeitgeist we’re in will really push the consumers’ need or demand for these interventions as we move along.”

THE BOUNDARY BETWEEN DISEASE AND HEALTH

Barbara A. Koenig, PhD, Associate Professor in the Department of Neurology and Neurological Sciences at the Stanford University Center for Biomedical Ethics in Palo Alto, California, echoed concern regarding the shifting boundary between disease and health. “The early years of debates about gene therapy, for example, were marked by claims that abuses were unlikely, since physicians would ‘of course’ limit their interventions to the treatment of easily identified states of ill health,” she told Neurology Reviews.

“Our experience with short stature calls these assumptions into question.... Different eras (or cultures) read the same symptom complexes in different ways,” she continued. “When we consider syndromes that include behavioral manifestations, such as memory disturbance, dementia, addiction, or learning disabilities, the boundaries become even fuzzier.... Neurologists, and patients, will have to act like socially engaged citizens concerned about the health of all, not simply as purveyors or consumers of heavily marketed medical products.”

David A. Stumpf, MD, PhD, Professor of Clinical Neurology at Northwestern University’s Feinberg School of Medicine in Chicago, believes that this is a critical time for the field of neurology. “We are entering an important era where science meets consciousness, arriving at some operational definitions and interventions,” he told Neurology Reviews. “Neurology will, because of these issues, become the most important medical specialty. We are entering the Millennium of the Mind, a sequel to the Decade of the Brain.”

Dr. Chatterjee is hopeful that at least some social guidelines can be established for the realm of cosmetic neurology. “Doing nothing is not the answer right now,” he asserted. “On the other hand, I am not convinced that legislation, at least in the concrete sense other than in very extreme cases, makes a lot of sense.... I think what we’re left with is trying to establish some set of acceptable social norms, where people feel that there is a set of principles under which one can operate. Coming together on what those norms are will require a fair amount of discussion and sorting out, if, in fact, that is possible.”

NR

—Colby Stong

Suggested Reading
Chatterjee A. Cosmetic neurology: the controversy over enhancing movement, mentation, and mood. Neurology. 2004;63:968-974.
Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry. 2002;51:189-192.
Yesavage JA, Mumenthaler MS, Taylor JL, et al. Donepezil and flight simulator performance: effects on retention of complex skills. Neurology. 2002;59:123-125.

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