This situation arises from a particular pharmaceutical landscape, and young medical professionals indicate future trends and current issues.

Consequently, medical neophytes may feel pressure from within and without to maintain their edge. Nine current and recent residents around the country and one medical student all spoke to me on condition of anonymity for themselves and their programs in order to recount their experiences without fear of embarrassing or implicating anyone. According to this group, they and their peers frequently imbibe alcohol to relax and caffeine to stay alert, and some legally get antidepressants. However, a minority turns illegally to ubiquitous medications. “You can’t just not show up for work one day,” an anesthesiology resident said, “no matter how crappy you feel—so you grab a Zofran out of the dispenser, or you get one of your friends to write you the antibiotic for an infection that you might not have but you’re afraid not to treat it. Being in office settings, you have easy access to all the meds the drug reps bring, so yeah, you’re inclined to grab a handful of Zoloft or whatever and see if it helps.”

Few medical professionals have quite this attitude or access. Nonetheless, the demand to be at one’s mental best is constant. One obstetrician/gynecologist “ate a lot of blueberries because I heard they improved memory.” Meanwhile, the above anesthesiologist’s roommate crushed and snorted “illegally obtained” Ritalin to study, and a neurologist knew four or five people “who’d taken other people’s Ritalin to stay up late to study for exams.” A third resident had once used her brother’s Ritalin in conjunction with caffeine to study in high school but decided not to do it again.

Because these students and residents are not using the drugs to make up for normal abilities they lack, but rather to enhance their performance, they effectively raise the standards for “normalcy,” and the ethical questions get complicated. But this situation arises from a particular pharmaceutical landscape, and young medical professionals indicate future trends and current issues.

By 1999, the United States was consuming 85 percent of the global supply of methylphenidate, a stimulant packaged as Ritalin and Concerta, to treat attention deficit hyperactivity disorder, commonly known as ADHD.[3] Methylphenidate and similar drugs can help healthy people—not by overcoming a deficit—but by allowing them to exceed their normal abilities. Ritalin, for instance, can improve spatial working memory, and Provigil (the marketing name for modafinil), designed to alleviate narcolepsy, can increase accuracy on mental tasks.[4] Since Ritalin, Provigil, and others are not prescribed for cognitive enhancement, it is illegal to use them thus. Yet over 20 studies in the last decade show people do.[5]

A review of those studies showed 5 to 9 percent of students through twelfth grade reported use of a “nonprescribed stimulant” in the last year, often Ritalin or Adderall (amphetamine and dextroamphetamine), as did 5 to 35 percent of college-aged respondents. Sixteen to 29 percent of people with prescriptions for stimulants had given away or sold the drug in their lifetime. Some people used these drugs to party, others to concentrate and elevate productivity.[6] Following a December 2007 commentary on neuroethics,[7] Nature asked its readers about their experiences with cognitive enhancement. Twenty percent of those who answered had used medication, mostly Ritalin or Provigil, without a diagnosed condition to enhance their concentration, memory, or problem-solving (another 14 percent used them with a prescription), and about three quarters of the respondents took such drugs once a month or more.[8]

The question of brain-boosting drugs has simmered in medical enclaves since at least 2004, when the American Medical Association’s ethics journal Virtual Mentor featured the topic. The British Medical Association followed suit with a conference and ensuing discussion paper, “Boosting your brainpower: ethical aspects of cognitive enhancements.”[9] The BMA went beyond questions of individual safety, agency, and social inequality to ask if we should invest in creating and testing drugs on healthy people to improve normal performance when illnesses and other disorders require therapy, and if we should encumber doctors with supervising enhancement and handling the fallout when things go wrong, whether from misuse or side-effects like hypertension and altered personalities.

The transformation from a paradigm that corrects impairment to one that enhances normalcy poses a complicated question for policy.

These discussions have remained largely hypothetical. However, some medical students and residents already boost their mental powers by taking drugs off label, which matters since doctors model behaviors for patients and provide legal access to medication. Moreover, the medical community largely polices itself. Thus, the norms of rising doctors will influence whatever regulation of cognitive enhancement, if any, occurs, and any successful regulation must in turn penetrate medical culture, which physicians and physicians-in-training collectively forge in the absence of some laws and in quiet deviation from others.

Almost all the recent or aspiring MDs quoted above agreed cognitive enhancement would spread assuming nothing else changed. A first-year student concluded, similarly to many, “If there’s money to be made, as long as people want that stuff, then there’ll be people interested in supplying it.” And demand exists. “If there’s a pill out there that can’t be abused,” explained the neurology resident, “but makes me more alert and a better doctor during the day and gives me energy to work out at the gym afterward, sure, I’d take it.” One MD-Ph.D. heard people contemplating nicotine patches or gum to study longer.

The potential for abuse, however, is key. Residents, like any doctor, can prescribe many if not all drugs, and they do so in what several called a “gray zone” between the letter of the law and tacit communal standards. Most states prohibit prescribing drugs outside a formal patient-physician relationship except in extreme cases. Yet at least three of the residents I spoke with bend that law and remain firmly within their group norms. According to the neurologist, “If I have a cold that I think needs an antibiotic, then I get a colleague to write the prescription. It’s not 100 percent right, but I do it out of convenience. But for narcotics or stimulants or anything that would raise eyebrows, I wouldn’t.” The MD-Ph.D. said, “There are some fairly benign medicines that most medical professionals would say writing an Rx for a friend wouldn’t be a big deal. And then there are the psych, pain, sleeping drugs that writing for anyone would raise eyebrows.” Another resident illustrated the gray zone: “All 3 of these [different prescriptions for family] would have flown under the radar and I used my clinical judgment to decide that they were or were not okay.”

If cognitive enhancement establishes itself among medical professionals, then “under the radar” and not yet “raising eyebrows” may annex stimulants like methylphenidate. An effective policy on cognitive enhancement, therefore, should reach this gray zone, which may require education and other ways to change medical culture, since medical cultural norms do not always coincide neatly with the law. Indeed, two studies indicate people who conduct themselves unprofessionally during medical training are significantly more likely to be disciplined by state medical boards later, but unprofessionalism is in the eye of beholding supervisors, deans, and board certification scores.[10] That discretion muddles whether discipline for inappropriate prescription and acquisition of drugs—which constitute 5 to 8 percent of violations in these studies—is uncommon because these incidents are rare or because only cases too far beyond the community’s pale are punished.

Dr. Gary Carr, president-elect of the Federation of State Physician Health Programs, believes “Education, education, education” can best translate any professional guidelines about cognitive enhancement into practice. Although he has yet to see data that demonstrate cognitive enhancement needs to be addressed among medical residents and students, he considers it “a slippery slope” from taking someone else’s Ritalin to trying amphetamines or cocaine. Furthermore, prescribing Ritalin or Provigil “without just cause” could incur “board action for practicing ‘outside the scope.’” Dr. Carr thinks physician health programs could address cognitive enhancement, if needed, since “most of us have some opportunity to lecture to the students/residents,” and the programs take referrals and provide treatment.

Yet physician health programs were created to prevent physician impairment, typically from alcohol and drug abuse, not physician enhancement. AMA ethics, too, emphasize physician impairment. Hence, just as a society’s shift from therapy to enhancement outstrips defined policy, detecting physician enhancement under the rubric of physician impairment appears difficult. Most medical students and residents are referred for poor performance to a physician health program. Improved performance would fly under the radar; only a secondary effect would register, such as the ethical impairment of forging a prescription or perhaps making a mistake in treatment when the cognitive enhancer wore off or misfired, such as increasing impulsive decision making.

The transformation from a paradigm that corrects impairment to one that enhances normalcy poses a complicated question for policy. In the interim, practices continue to develop. As one recent MD said, “My personal belief is, you can drink, smoke, medicate as much as you want as long as it does not impair your personal or professional life.” She may be right—for now.

Mark Meier is a freelance writer with a particular interest in ethics, identity, and social structure.

Notes

[1] Laura K. Barger, et al. 2006, “Impacts of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures,” PLoS Medicine 3 (12), e487 doi:10.1371/journal.pmed.0030487. Current ACGME regulations limit shifts to 30 consecutive hours, with 10 hours off in between, and no more than 80 hours average per week over any four-week period. Some exceptions are allowed, and violations do occur.

[2] Amy M. Fahrenkopf, et al., “Rates of medication errors among depressed and burnt out residents: prospective cohort study,” British Medical Journal (2008), doi: 10.1136/bmj.39469.763218.BE

[3] “International Narcotics Control Board 1999 Annual Report,” available at http://www.incb.org/incb/annual_report.html.

[4] The results of these and other small clinical trials are summarized in the British Medical Association’s discussion paper, “Boosting your brainpower: ethical aspects of cognitive enhancements” from November 2007, available at http://www.bma.org.uk/ap.nsf/content/CognitiveEnhancement2007.

[5] T.E. Wilens, et al, “Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature,” Journal of the American Academy of Child and Adolescent Psychiatry 47 (1) (2008): 21-31.

[6] Ibid.

[7] Barbara Sahakian and Sharon Morein-Zamir, “Professor’s little helper,” Nature 450 (2007): 1157-59.

[8] The full survey results are available at http://network.nature.com/forums/naturenewsandopinion/1309.

[9] The August 2004 issue of Virtual Mentor (virtualmentor.ama-assn.org) included Martha Farrah’s “Neuroethics,” Abe Schwabe’s “Ethical Issues in the Application and Prescription of CNS Interventions,” and Anjan Chatterjee’s “Cosmetic Neurology: For Physicians the Future is Now”; the same journal in its February 2007 issue printed Steffen K. Rosahl’s “Neuroprosthetics and Neuroenhancement: Can We Draw a Line?” The New England Journal of Medicine in September 15, 2005, published an essay by Richard Kadison of Harvard’s Health Services, “Getting an Edge—Use of Stimulants and Antidepressants in College,” and in November 2007, the BMA released its discussion paper. A month later, Nature published the commentary which led to its informal survey of readers, a story The New York Times picked up in Benedict Carey’s “Brain Enhancement Is Wrong, Right?’ from March 9, 2008.

[10] Maxine Papadakis, et al., “Disciplinary Action by Medical Boards and Prior Behavior in Medical School,” New England Journal of Medicine 353 (25) (2005): 2673-83. Maxine Papadakis, et al., “Performance during Internal Medicine Residency Training and Subsequent Disciplinary Action by State Licensing Boards,” Annals of Internal Medicine 148 (11) (2008): 869-76.

“Pssst,” he says. “You want to win gold? Guaranteed to help. And perfectly legal.”

“What is it?” you ask, as he shows you a mysterious device, smaller than a credit card and with wires dangling from it.

“Intracranial transducers,’” he says in practiced English, pointing to the ends of the wires. “Stick them in your ears and they focus the brain, increase blood oxygen, prepare muscles for action. Made here in China.”

“So it’s a doping device!” you say with disgust.

“No, no,” the man exclaims in a hoarse whisper, looking around to make sure no one else has heard your incriminating comment. “Like I said, totally legal.”

“So what is it called?” you ask.

He looks askance again, then leans over and whispers in your ear: “‘iPod,’” he says. “We call it ‘iPod.’ It worked for Phelps. It can work for you.”

***

It is now a widely known fact that Michael Phelps, winner of a record-breaking eight gold medals in this year’s Olympics, is an iPod fanatic. In the minutes before diving into the pool, those trademark white wires were almost invariably hanging from his ears. He has confessed at various times to using tunes by Eminem, Young Jeezy, Lil’ Wayne and Jay-Z to motivate him and enhance his concentration.

When broken down to its mechanical elements, an iPod is nothing more, and nothing less, than what my hypothetical Chinese huckster was pitching—a device that transduces electrical energy into acoustical energy, namely music.

You see where I am going with this. And before I go any further, why don’t you get it out of your system? Let me have it. I know what’s coming because soon after I began to wonder about the parallels between iPoding and doping, an Israel-based medical doctor and scientist with whom I have communicated occasionally in the past—Alexei Koudinov, who among other things edits an online scientific publication called The Doping Journal—sent me a blog in which he raised the same issue. And that blog, I saw, had led to instant and effusive derision by his online readers.

“Who pays this guy to think up things like this?” one respondent wrote, after Koudinov argued the undoubtedly extreme case that Phelps should give up his medals. Others called the idea that music should be classified as a performance enhancer “asinine,” “silliness,” “a crock,” “ridiculous,” and “mean-spirited.”

One clever commentator claimed that “The writer of the article is qualified
to write for that [Doping] Journal: He is a Dope!” Another, less clever, called Koudinov’s posting “a waste of ink.” In fact, as with most online postings, no ink was involved.

But let’s pursue the idea a bit further. When broken down to its mechanical elements, an iPod is nothing more, and nothing less, than what my hypothetical Chinese huckster was pitching—a device that transduces electrical energy into acoustical energy, namely music. And as everyone knows, music can have profound psychological and physiological effects. It can relax a listener. It can anger or enthrall. It can excavate deep emotions and energy.

If that is not specific enough, consider research published in the Journal of Nursing Research in 2003, which showed that hospitalized infants who had music played for them had significantly higher oxygen levels in their blood than other babies . Now consider that the 2008 World Anti-Doping Code of the World Anti-Doping Agency, in Article M1 under the category of “Prohibited Methods,” bans methods of “artificially enhancing the uptake, transport or delivery of oxygen….”

I suppose this raises the interesting legal and philosophical question of what is “artificial.” In the words of one especially cynical blogger: “As just about everyone knows, breathing increases blood oxygenation. Should this also be considered illegal?” I won’t go that far. But even if normal breathing is acceptable, what about the arguably less-natural activities known as deep breathing or stretching or limbering up?

Moreover, music can affect more than mere oxygen levels. Koudinov cites research by Stefan Koelsch of the Max Planck Institute for Human Cognitive and Brain Sciences in Leipzig, Germany, who has published research on biological responses to music. According to Koelsch, music can induce biochemical “relaxing effects.” Given all the talk during this year’s Olympics about the risks and downsides of “having the jitters,” which can throw even the best of gymnasts off their balance beams, relaxation is clearly a big potential benefit.

Yet anti-jitter drugs, such as beta blockers, are expressly prohibited in many Olympic sports (including marksmanship, as evidenced last week when the North Korean Olympic shooter Kim Jong Su was stripped of his silver and bronze medals after blood tests came up positive for propranolol, which can slow a heart that is racing from nervousness and, in so doing, reduce anxiety and enhance concentration).

Phelps may even have received a double benefit by yanking out his ear buds in the last minute or two before competing. Research published in 2005 suggests that intense music followed by a sudden silent pause may be just the ticket for someone poised at the edge of an Olympic pool, since the music itself can boost arousal and the sudden silence that follows can induce, in handy sequence, a wave of relaxation.

“Music, especially in trained subjects, may first concentrate attention during faster rhythms, then induce relaxation during pauses,” that study concluded.

Now that the tomatoes are well on their way to my e-podium, let me tell you that I raise these points not to call for an end to music at the Olympics, much less for an end to respiration, oxygenating though both may be. Rather my goal here is to make a distinction between the rationales that many in the anti-doping community use to justify their anti-doping efforts and the single rationale that, in my opinion, is the only one that stands up to real scrutiny.

The arguments against doping come down to two major moralistic themes:

1) Doping is not fair because it rewards those who artificially augment their abilities instead of rewarding what sports are supposed to be about, namely hard work and perseverance.

2) Doping often carries health risks and we should not encourage or inspire people to put their health at risk, and we should especially not inspire children—who are known to worship sports heroes—to take such risks.

By my analysis, No. 1 falls apart because, the Declaration of Independence notwithstanding, all men and women are not created equal. No amount of training is going to make me a gold medal sprinter or swimmer. Some folks have extraordinary genetic potential (indeed, the Chinese seem very good at picking them out early and incarcerating them in training camps). Others are born into environmental privilege, including access to coaches or high-tech running shoes (which are legal, while artificial spring-loaded prosthetic feet are not, of course). The Olympics do not exclude the genetic and environmental Haves out of a concern for fairness to the Have-nots like me. All are invited to compete as though equal, even though we know which group is going to win. So what is so morally obvious about the need to exclude the Have-drugs out of fairness to the Have-no- or Use-no-drugs?

No. 2 falls apart because society already allows adults to take risks as long as they understand them. (Or purport to understand them. Consider the case of Fort Lauderdale kite-boarder Kevin Kearney, whose decision to make sport of Tropical Storm Faye’s recent winds resulted in his getting tossed hundreds of yards through the air before being slammed against a building and hospitalized in critical condition. Arguably stupid, but not illegal.) As for influencing kids, well, the law allows adults to do all kinds of stuff that’s a bad influence on kids—smoke cigarettes, drink alcohol, engage in unprotected intercourse. Allowing adult athletes to dope does not mean that kids must ethically be allowed to do the same.

No, there are no moral reasons to oppose music, meditation, or methamphetamine in sports. But there is one water-tight reason, and it is a reason that will resonate with every kid who grew up with a parent. The reason, in short, is, “Because I said so.” Not because an individual “I” said so, of course, but because those who have been elevated to the status of rulemakers have agreed on the rule. And that is that.

As Gary Wadler, chairman of the World Anti-Doping Agency’s Prohibited List and Methods Committee explained at a recent Center for American Progress event on athletic enhancement and reiterated in a later interview: “These things are arbitrary. But people settle on a set of rules.”

There is no moral reason why the distance from home plate to first base must be 90 feet, Wadler said, but people have agreed on that distance. And unless and until the rules get changed, that’s the way it’s going to be. If you don’t like it, you don’t have to play. But if you do play, that’s a rule you’ll have to follow.

It may sound shallow and less convincing than relying on some grand ethical theory of fair play and the quest for human excellence. And let’s face it: nothing was more irritating than hearing one’s parent fall back on the seemingly lame comeback of “Because I said so.” Surely our “Whys?” deserved better than that.

But it is good to remember—especially in these times of great religious and moral fervor, when presidential candidates feel oppressively obliged to affirm their belief in Christ as their personal savior and presidents invoke disproportionately righteous reasons for going to war—that not every decision is, in fact, a big fat moral decision. Sometimes we should just do things because those are the rules we have agreed upon. Because, for example, the Constitution says so, or the laws passed by our representatives in Congress say so. Removing the fatty cover of moral certitude when morality is not, in fact, the best argument for action would simplify life, make us more honest and, perhaps most important, put us more in the habit of acting on the basis of evidence rather than on received wisdom and protestations of personal piety.

You question that? Well too bad. When you’re in my column space, you play by my rules.

Now go to bed.

Rick Weiss is a Senior Fellow at the Center for American Progress and Science Progress.

When it comes to enhancing athletic performance, where, then, is the line between laser eye surgery and anabolic steroid use? Certainly there is a broad spectrum between the two, but at what point does performance enhancement stop being acceptable?

This was one of the many questions raised by the panelists Friday at a Center for American Progress event. Michael Werner, President of The Werner Group, postulated that for many Americans the line of unacceptability is drawn at chemical enhancements, as opposed to surgical or equipment-based ones.

Arthur Caplan, Director of the Center for Bioethics at the University of Pennsylvania, argued that drugs and even drastic equipment improvements can undermine continuity, something we value in our sports. We can no longer compare modern sports heroes to stars of the past (or even to their own prior performances) if modern athletes artificially enhance their performance.

The natural limitation of humans, Caplan says, is what differentiates between a “performance” and an “exhibition.” While we might be interested in watching jumping competitions between two men with rocket-boosted legs, we probably wouldn’t consider it sport or attribute the winner’s victory to his training or athleticism. Consider the baseball player who uses drugs to enable him to hit massive amounts of home runs. In his case we lose the sense of baseball’s history and cannot clearly distinguish what part of his record is athletic performance and what is exhibition.

Another concern about doping is safety. Gary I. Wadler, M.D., chairman of the World Anti-Doping Agency’s Prohibited List and Methods Sub-Committee, presented statistics showing that children are using anabolic steroids younger and younger in order to ape their heroes. High school athletes especially turn to steroids as a response to intense pressure to perform from parents, coaches, and scouts. Caplan said that this pressure amounts to coercion when applied to adults who could otherwise be assumed to have free choice.

Noah Walker, a consultant at the Center for American Progress Action Fund and a former professional baseball player, confirmed that the widespread use of performance-enhancing drugs makes it very difficult to compete because the players who use are often heavily rewarded with playing time and lucrative contracts.

One major problem is that, even if legislators and health officials could agree on what types of enhancements should be illegal, most of them are incredibly difficult to detect. A recent Nature article, “The Science of Doping” reports an unacceptably high false-positive rate in the types of drug tests that Olympians take in Beijing.

Yet testing for enhancement will likely become more difficult. Wadler and Caplan both agreed that the enhancement of the future will be “gene doping,” something we will probably encounter before the 2012 Olympics. Drugs may be difficult to test for accurately, but imagine testing athletes for tweaked DNA or extra cells. Clearly, we need better science to test for doping if we want to preserve the sports we love.

An upcoming Center for American Progress panel, “Sports Doping and the Age of Enhancement,” will examine these issues from the standpoints of science, ethics, and industry. Join us this Friday, August 8, from 12:00 pm to 1:30 pm.

In one sense there is no issue: No one in any competitive enterprise should have an unfair advantage. So stated the point is a truism, for who is in favor of “unfairness”? However, it is also clear that detection is going to become more of a challenge. One strategy might resort to genetic interventions that result in the production of more naturally occurring proteins that in turn spur the body’s manufacture of oxygen-carrying red blood cells or of muscle cells. “Gene doping” would thus represent an “advance” over the artificial introduction of the compounds themselves, like the drug erythropoietin or EPO, which regulates red blood cells and can be detected.

Some argue that the whole debate is misplaced, that enhancement already takes place among athletes in many different ways, like using high altitude chambers or special elbow surgery that may improve strength. Others contend that, though it may be hard to draw lines, the point of sport is the combination of personal initiative along with making the most of natural gifts, that our very humanness is at stake if we succumb to the hubristic pursuit of perfection rather than the achievement of excellence. (Writing here at Science Progress, Arthur Caplan also considered the ethical questions of doping, including those involved in recent major league baseball scandals.)

The legal standards applied in both amateur and professional sports make this more than an academic debate. Still more importantly, the enhancement issue in sport is the canary in the coal mine for a much wider societal debate about how far the life sciences can and should take us, a profound question that seems to be unfolding as a key theme of the 21st century.

• 20 percent of respondents report using medications to increase memory retention, concentration or focus.
• 60 percent of those who admitted non-medical use of cognitive-enhancing drugs used Ritalin.
• 44 percent of the admitting respondents used Provigil, known generically as modafinil.
• 15 percent admitted use beta-blockers.
• 9 out 10 respondents said they used the drugs to improve concentration and attention.

Science Progress advisory board member Martha Farah expressed concern about the ethical use of brain-enhancing drugs during a Seed Magazine-sponsored briefing on the Hill last month:

If higher productivity can come in a harmless pill, Farah wondered if workers might find themselves saying one day, “I want this job, but I don’t want to have to take a drug to get it.”

If Wired’s coverage is any indication, her concerns may already be manifest in some workplaces. In a recent edition of the magazine’s Mr. Know-It-All column, a reader asks the following question:

One of my coworkers, a rising star at the firm, is using unprescribed modafinil to work crazy hours. Our boss has started getting on my case for not being as productive. Should I tell him about my coworker’s pharmaceutical enhancement? Or should I start taking modafinil, too?

The question of what sort of social or governmental rules will govern such ethical choices about brain enhancement remains unanswered, but it’s obvious that deliberations have already begun.

Also in the podcast, Malcolm Dando of the University of Bradford responds by calling attention to the “dual-use dilemma,” the fact that new technologies can be used for malign purposes as well as benign ones. Oxford neuroscientist Russel Foster discusses the notion of sleepless soldiers and government oversight and his responsibility as a bench scientist to inform the government about how the military can apply scientific research.

For more discussion on Moreno’s book Mind Wars and military neuroscience research, there’s video from a recent Dana Foundation event with Moreno, Foster, Dando, and NYT columnist William Safire.