Walking the tightrope: ethics in treating ADHD Dora Wynchank
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Dora Wynchank. Should we be worried? Increasing numbers getting stimulants Children Adolescents Adults Stimulant use increased fourfold from 1987 to 1996.
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Slide 1
Dora Wynchank
Slide 2
Should we be worried? Increasing numbers getting stimulants
Children Adolescents Adults Stimulant use increased fourfold from
1987 to 1996 0.6% to 2.4% Among under 18 year olds in the U.S.A
Approx 2.8% US youths, aged 5 to 18, on methylphenidate in mid-1995
(Safer et al, 1996)
Slide 3
Should we be worried? 1990-1995: 2.5x increase in stimulant
treatment This steep increase in under 18 year olds levelled out
until 2002 For very young children, stimulant use has remained
stable
Slide 4
Ethical Dilemma Request for stimulant medication by many
patients who do not meet the criteria for ADHD
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in your practice?
Slide 6
First step: defining normal Normal patients defined as those
with insufficient signs, symptoms, or abnormal test results to
satisfy criteria for mental health condition Boundary between
disease and non disease often unclear If normal adults request
neuroenhancement, they are not patients because they do not require
treatment
Slide 7
First step: defining normal However, what defines a
doctorpatient relationship? It depends on the mutual decision of
the patient and doctor to enter into the relationship Thus, the
adult requesting neuroenhancement becomes a patient when the
psychiatrist/ neurologist evaluates or prescribes treatment
Slide 8
Defining normal Assuming doctor patient relationship exists
patient requests neuroenhancement Doctor still has full ethical and
professional responsibilities to the patient These responsibilities
to the patient continue until the relationship is ended
Slide 9
Who are the non diagnosed users? University students acquire
drug illegally (Babcock et al, 2000) Up to 33% of college students
misuse stimulants to cope with stressful academic demands
http://www.sciencedaily.com/releases/2008/04/080407195349.htm
http://www.sciencedaily.com/releases/2008/04/080407195349.htm
Prevalence rates 5 38%
Slide 10
Who are the non diagnosed users? Recent study of university
students 38% used stimulants at least once by Year Four (Arria et
al, 2012) Non medical use of stimulants associated with academic
difficulties alcohol and cannabis use disorder declining Grade
Point Average
Slide 11
Who are the non diagnosed users? Children with pushy parents
DSM criteria too vague Teachers accused of insisting on stimulants
for disorderly children Weight loss Vigilance during night shift
(Israeli Medical Association) Military personnel Alzheimers
(American Academy of Neurology 2009) use of cholinesterase
inhibitors (e.g., donepezil) to treat normal age-related memory
changes
Slide 12
Why use stimulants? To improve alertness, wakefulness and
concentration better retention of information Similar to athletes
doping In students, higher tolerance for alcohol (Babcock et al,
2000)
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Ethical questions Do stimulants work in people who do not have
a diagnosis of ADHD? Do stimulants cause harm when given to normal
people? What are the duties of the physician when facing parents
who want medication for a child who is underperforming for reasons
other than a diagnosis of ADHD?
Slide 16
Discussion
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Do stimulants work in normal people... No Literature divided
Stimulants improve alertness and cause insomnia Cognitive effects
of stimulants on normal people not clear despite the volume of
research carried out But no improvement in concentration or fluency
on cognitive testing (Safer et al, 1996) Stimulants cause
impairment in previously learnt spatial tasks (Elliott et al,
1997)
Slide 18
Do stimulants work in normal people... No Effects on the
executive functions working memory cognitive control are not
reliable Metanalysis: no consistent evidence for neuroenhancement
effects of MPH (Repantis D et al, 2010) MPH not found to enhance
attention Effects are complex, not be uniformly positive across all
dose levels or age groups, and do not enhance all aspects of
executive function or memory (Turner et al 2003) Long-term use of
off-label medications for neuroenhancement in normal patients are
not known and may not be known for many years
Slide 19
Do stimulants work in normal people... No Stimulants improve
alertness and cause insomnia Are longer hours spent awake and
cramming helpful? What improves memory is repetition Revising and
reviewing the material Last minute cramming is not the best way to
consolidate long term memory
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Do stimulants work in normal peopleYes Stimulants do improve
cognitive function in normal subjects Low doses of stimulants focus
attention and improve executive function in normal and ADHD
subjects Improvement measured on a learning task in normal boys and
men with amphetamine definite increase in learning (Rapoport et al,
1980) Ability to focus attention, manipulate information in working
memory flexibly control their responses is improved (Sahakian et
al, 2007)
Slide 21
Do stimulants work in normal people...yes Spatial working
memory and planning improve (Elliott et al, 1997) More vigilant and
shorter response times Novel problem-solving and planning also
improved (Elliott et al, 1997) Metanalysis: positive effect on
memory of healthy individuals was found (Repantis D et al,
2010)
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Discussion
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Do stimulants cause harm when given to normal people? Research
not fully conclusive No detailed long term studies in normal
subjects Methylphenidate increases activity levels, arousal,
talkativeness, and mood in normal subjects (Chait et al, 1994) Some
people have increased levels of anxiety, dysphoria and fatigue
(Clark et al, 1986)
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Do stimulants cause harm when given to normal people? In
summary, the effects of stimulants on normal individuals are mild
but helpful Drugs with the fewest side effects are methylphenidate
and modafinil prescribed mostly for narcolepsy and also ADHD
Slide 25
Patient has extreme side effect What is your legal
position?
Slide 26
Discussion
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Should cognitive enhancing drugs be prescribed? We undertake
many activities to enhance attention Common sense The following
improve brain function exercise (Erikson et al, 2009) nutrition
(Almeida et al, 2002) adequate sleep (Boonstra et al, 2007)
teaching (Draganski et al, 2004) reading (Schlaggar et al, 2007)
Are drugs morally equivalent to other familiar enhancements?
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Objections 2 broad categories: problems for the individual user
problems for society
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Are we enhancing patient autonomy by prescribing cognitive
enhancers? Could we be limiting it?
Slide 30
Ethical principles: patient autonomy Patient has right to
refuse or choose treatment Does autonomy grant patients the right
to try cognitive enhancement?
Slide 31
Ethical principles: patient autonomy Does cognitive enhancement
impair autonomy? Especially children who cannot choose their
medication or refuse it
Slide 32
Doing good for patients Are cognitive enhancers good for
us?
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Ethical principles: beneficence Does cognitive enhancement
allow us to act in best interest of the patient? If long term
adverse effects exist, perhaps prescribing them is not beneficial
to the patient May even cause harm
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First do no harm How could we be harming patients?
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Ethical principles: non-maleficence First do no harm
Possibility of serious side effects Brain is the most complex and
important human organ Perhaps premature memory loss and cognitive
decline? Interfering with normal brain function dangerous
Slide 36
Ethical principles: non-maleficence Which 'limitations' are
there for a good reason? Normal forgetting rates is important
Irrelevant information designed to be forgotten Synaptic pruning
important part of good brain function How damaging is excessive
memory? Important in pathogenesis of PTSD
Slide 37
Ethical principles: non-maleficence Is cognitive enhancement
unnatural? How natural are our lives? Also, be aware of placebo
effect if prescribing
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Is cognitive enhancement fair?
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Ethical principles: justice Distribution of scarce health
resources: distributive justice Who gets what treatment ? If
wealthy had sole access unjust Would each dose be cheap? There are
many examples of unequal access to benefits in society, including
private schools
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Ethical principles: justice Could employers coerce employees
into taking enhancers to improved performance? Would the widespread
use of enhancers change the standards of what constitutes normal
cognitive function? Would this disadvantage those who choose not to
enhance?
Slide 41
Ethics Committee of Israeli Medical Association Traditional
role of medicine is to maintain patient's health improve quality of
life With request for neuroenhancement if patient healthy inherent
risk is marginal Doctor should examine any request professionally,
but is not obliged to accept Off label usage of medication requires
informed consent from patient Periodic evaluation of treatment
effectiveness is necessary
Slide 42
Ethical principles: justice Use should be regulated and
monitored in certain situations use by healthy children no autonomy
insufficient information on their effects in the developing
brain
Slide 43
Ethical principles: justice Competitive situations: entrance
exams cognitively enhanced have unfair advantage guidelines need to
be devised Would cognitive enhancers improve overall learning or
simply boost exam performance? With temporarily improved exam
performance, exam not a valid measure of the ability of the student
Therefore unfair
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Is it truthful?
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Ethical principles: truthfulness Is it cheating? Is it doping?
Would it be against the rules? Should the rules be changed?
Slide 46
Ethical principles: truthfulness Does cognitive enhancement
bypass real effort in obtaining results? No gain without pain
Emotional component struggle is worth it moral benefit
Slide 47
Ethical principles: truthfulness Many shortcuts to performing
better Study guides and extra lessons Is cognitive enhancement not
yet another practice? Who would stand to gain financially?
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Is the doctors dignity compromised if pressured to prescribe in
the absence of a medical diagnosis?
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Ethical principles: dignity Is the doctors dignity compromised?
Answer depends on the doctors attitude to practice of medicine
Healers view prescribing to normal individuals as inappropriate
Therapy is about treating disease
Slide 50
Ethical principles: dignity If regard medicine broadly helping
patients have better quality of life More open Enhancement is about
improving normal abilities Fukayama says: the original purpose of
medicine is to heal the sick, not turn healthy people into gods.
Also suggests that public policy should restrict research for
enhancement (2002)
Slide 51
Where does this leave us? In future, with internet, many may
purchase scheduled medication Medications may be developed for
improving cognition and memory in normal persons (de Jongh R, et
al. Botox for the brain: enhancement of cognition, mood and
pro-social behavior and blunting of unwanted memories. Neurosci
Biobehav Rev 2008;32:760 776) We all need to engage with all the
issues
Slide 52
Where does this leave us? Devise clear guidelines supervised
access to safe and effective cognitive-enhancers All stake holders
make decisions Dialogue to create boundaries and regulations
Restrict in certain competitive situations Regulations similar to
those in place limiting doping in sporting events
Slide 53
Where does this leave us? Dont rely on pharmacology alone to
improve memory and attention Use holistic approach psychotherapy,
nutrition, good sleep hygiene and exercise Understand more about
their advantages and disadvantages Naturalistic setting for
research Only once the potential harm of these agents has been
clarified, will clinicians be able to decide on their usage
Slide 54
I believe in an open mind, but not so open your brains fall
out.
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Discussion
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Ethical principles: dignity Traditional goals of medicine
prevent and diagnose disease or injury cure or treat the
disease/injury reduce suffering or, if that is not possible, or
help patients to cope educate patients about disease and prognosis
help patients to die in peace and with dignity reassure the worried
well Cosmetic surgery uses medical skill to enhance the well- being
of normal persons
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socially useful practices acceptable to the profession and
society Illegitimate Prohibited
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Ethical principles: dignity From this perspective, prescribing
neuroenhancement lies outside the core domain of traditional
medical practice is not ethically obligatory Is it illegitimate or
an acceptable practice? therefore ethically permissible