Pediatric neuroenhancement: ethical, legal, social, and neurodevelopmental implications.

The use of prescription medication to augment cognitive or affective function in healthy persons-or neuroenhancement-is increasing in adult and pediatric populations. In children and adolescents, neuroenhancement appears to be increasing in parallel to the rising rates of attention-deficit disorder diagnoses and stimulant medication prescriptions, and the opportunities for medication diversion. Pediatric neuroenhancement remains a particularly unsettled and value-laden practice, often without appropriate goals or justification. Pediatric neuroenhancement presents its own ethical, social, legal, and developmental issues, including the fiduciary responsibility of physicians caring for children, the special integrity of the doctor-child-parent relationship, the vulnerability of children to various forms of coercion, distributive justice in school settings, and the moral obligation of physicians to prevent misuse of medication. Neurodevelopmental issues include the importance of evolving personal authenticity during childhood and adolescence, the emergence of individual decision-making capacities, and the process of developing autonomy. This Ethics, Law, and Humanities Committee position paper, endorsed by the American Academy of Neurology, Child Neurology Society, and American Neurological Association, focuses on various implications of pediatric neuroenhancement and outlines discussion points in responding to neuroenhancement requests from parents or adolescents. Based on currently available data and the balance of ethics issues reviewed in this position paper, neuroenhancement in legally and developmentally nonautonomous children and adolescents without a diagnosis of a neurologic disorder is not justifiable. In nearly autonomous adolescents, the fiduciary obligation of the physician may be weaker, but the prescription of neuroenhancements is inadvisable because of numerous social, developmental, and professional integrity issues.

Upholding professionalism: the disciplinary process of the American Academy of Neurology.

OBJECTIVE: To review the disciplinary process by which the American Academy of Neurology (AAN) enforces its formalized standards of professional conduct. METHODS: We reviewed the AAN's Disciplinary Action Policy. We tracked the elapsed time from receipt to final decision of all allegations ("complaints") of improper conduct by AAN members submitted from 2004 to 2009. We placed each complaint into 1 of 4 categories: allegations of 1) improper expert witness testimony; 2) substandard care; 3) unprofessional conduct; 4) or both 2 and 3. We noted the type of complainant (AAN member or nonmember) and the final outcome for each complaint. RESULTS: The AAN's disciplinary process is a 5-step procedure with multiple reviewing bodies. From 2004 to 2009, the AAN received 3-16 complaints per year (total 58), with 16 filed each year in 2008 and 2009. Thirty-one complaints (53%) were submitted by nonmembers and 27 (47%) by members. Disciplinary action was recommended for 6 complaints (10.3%) with action taken in 3 (5.1%) and the member resigning in lieu of action in 3 (5.1%). The average number of days from receipt of complaint to final decision was 537, with an average of 890 days from 2004 to 2006, decreased to 184 days from 2007 to 2009. CONCLUSIONS: Recent revisions to the disciplinary process have increased efficiency and enhanced procedural safeguards. The AAN determined a mean of 12 months, from receipt of complaint to final decision rendered, is an appropriate benchmark when handling complaints. The AAN's disciplinary process upholds standards of professional conduct for AAN members and protects members from unsubstantiated complaints.

Responding to requests from adult patients for neuroenhancements: guidance of the Ethics, Law and Humanities Committee.

In the last decade, persons who have no diagnosed medical or mental health condition are increasingly seeking and utilizing, for the ostensible purpose of enhancing their memory or cognitive skills, prescription drugs that were originally developed to improve executive function or memory in persons diagnosed with disorders such as attention deficit hyperactivity disorder or Alzheimer disease. Evidence suggests that this practice, now known as neuroenhancement, is gathering momentum. As a result, neurologists may be encountering patients without a diagnosed illness asking for medications with the goal of improving their memory, cognitive focus, or attention span. Strong arguments have been made for and against this practice, often reflecting strongly held convictions concerning the appropriate practice of medicine. The purpose of this report is to provide neurologists with an overview of the ethical, legal, and social issues surrounding the use of pharmaceuticals prescribed to enhance or augment normal cognitive or affective functioning, as well as practical guidance for responding to an adult patient's request for neuroenhancement.

Invited article: professionalism in neurology: the role of law.

Professionalism may be defined as the obligation of the physician to uphold the primacy of patients' interests, to achieve and maintain medical competency, and to abide by high ethical standards. Recent commentary has suggested that medical professionalism is being threatened by commercialism and the legal system. Consideration of judicial rulings centered on primacy of patients' interests (informed consent, end-of-life care, and conflicts of interest), medical competence (standard of care in medical malpractice cases, medical futility cases, and confidentiality of peer review), and enforcement of ethical standards (peer review by professional organizations) demonstrates that the law generally defers to standards set by the medical profession, but competing views over what health care model is operative may generate non-deferential outcomes.

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education duty hour requirements may affect residents' understanding and practice of professionalism. OBJECTIVE: We explored residents' perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements. DESIGN: Anonymous cross-sectional survey. PARTICIPANTS: Internal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312). MEASUREMENTS: Using Likert scales and open-ended questions, the questionnaire explored the following: residents' attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism. RESULTS: One hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing professionalism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork. CONCLUSIONS: Residents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.