Can Pediatric Neuroenhancement Be Justified?
Neuroenhancement is "the use of prescription medication by healthy persons for the purpose of augmenting normal cognitive or affective function"—a practice that is increasing in adult, pediatric, and adolescent populations.1
Drugs typically prescribed for neuroenhancement are those used for treating attention deficit/hyperactivity disorder (ADHD) (methylphenidate or amphetamines);1 drugs used for cognitive impairment or dementia (acetylcholinesterase inhibitors and memantine);2 antidepressants;3 and modafinil.4 This practice raises serious ethical, legal, and social issues—especially in the pediatric population, for which neurodevelopmental concerns must be taken into account.
Neuroenhancement in Adults
According to 2009 Guidelines for Off-Label Prescription of Neuroenhancement Drugs in Adults issued by the Ethics, Law, and Humanities Committee (ELHC) of the American Academy of Neurology (AAN),5 adults seek neuroenhancement to "improve memory, cognitive skills, or affective functioning."5 The authors of the guidelines note that enhancing the well-being of normal individuals is an acceptable component of medicine.
For example, non-medically necessary cosmetic surgery may improve the patient's quality of life, self-image, and social functioning. Similarly, neuroenhancement may improve the patient's cognitive, affective, academic, or employment performance, leading to positive social outcomes. Used appropriately, with thorough assessment of the patient and informed consent, the risk-benefit ratio may favor neuroenhancement.5 On the other hand, evidence for efficacy and safety of neuroenhancement medication in healthy adults is "limited."5, 6 Additionally, these drugs can be addictive, leading to negative individual and social repercussions.7
According to the AAN Guidelines, the prescription of medications for neuroenhancement is not legally or ethically obligatory. However, it is legally and ethically permissible in the United States. Refusal to prescribe these agents or discontinuation once they have been prescribed is also legally and ethically permissible.5
The Complex Ethical Issues of Neuroenhancement in Children
Controversy regarding neuroenhancing drugs is heightened in children. Proponents regard neuroenhancements as "study aids," with potentially positive academic benefits and similar goals to traditional behavior modification techniques.8 Opponents cite lack of safety and efficacy evidence and serious risks. To address these questions, the ELHC published a position paper, endorsed by AAN, the Child Neurology Society, and the American Neurological Association, focusing on the ethical, legal, social, and neurodevelopmental implications of pediatric neuroenhancement, with particular emphasis on stimulant use.1