Research review
The Neurocognitive Enhancement of Surgeons: An Ethical Perspective

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Neurocognitive enhancement is a rapidly expanding scientific field. The vast ethical implications of this developing field for surgical practice have yet to be considered within the literature. This article outlines the reasons surgeons may, in the near future, consider using neurocognitive enhancement and addresses the resulting significant ethical implications of this. We do not seek to support or denounce the potential role of neurocognitive enhancement in surgeons, but to stimulate a debate, which, with ever-increasing levels of stimulant use in schools and colleges, and with a pharmaceutical industry driving the creation of new neuroactive products, has now become a necessity.

Introduction

Neurocognitive enhancement, the practice of improving the neurological function of individuals who are disease free, has been the subject of recent media, political, and ethical interest [1, 2, 3]. Nonpharmacological methods, such as Transcranial Magnetic Stimulation, Brain–Machine interfaces, and neurosurgical implantation of devices and tissue are all at early stages of development, with most research still focused on their role alleviating pathology [4, 5, 6, 7]. Psychopharmacological enhancement is further developed and has undergone more extensive evaluation. Prescription medications such as donepezil (Aricept; Eisai, Tokyo, Japan), modafinil (Provigil; Cephalon Inc., Frazer, PA), methylphenidate (Ritalin; Novartis, Bern, Switzerland), and bromocriptine (Parlodel; Novartis), originally developed to treat neurological and psychiatric illnesses, are being increasingly investigated for their potential to enhance memory, cognition, and executive function in healthy individuals. While this may sound radical, for many healthy people enhancing normal neurocognitive function is already a fact of life. In the United States the proportion of boys taking methylphenidate is at epidemic levels, exceeding the highest estimated prevalence of Attention Deficit Hyperactivity Disorder [8], which suggests that normal childhood high spirits are being dampened by pharmacological means to enhance the educational experience. This is not limited to schools; an estimated 16% of students at some United States universities take prescription medication as study aids [9]. Finally, nonprescription supplements are being increasingly used in an attempt to improve memory, cognition, and ward off fatigue. Ginkgo biloba, a Chinese herbal medicine, is now a billion dollar industry in the United States alone [10], despite only limited effects on cognition [11]. The field of neurocognitive enhancement is already here and is growing.

The vast ethical implications of this developing field have been partly addressed within the literature, but from the view of prescriber [12] or society as a whole [13]; no one has considered the implications of neurocognitive enhancement for current surgical practice. This article outlines why surgeons may soon consider using prescription medications, or technological interventions, originally designed to treat neuropsychological pathologies, to enhance their performance. We focus predominantly on drugs, as the evidence suggests this is the more imminent and likely form of neurocognitive enhancement that surgeons may consider, and address the resulting significant ethical implications of these actions. We do not seek to support nor denounce the potential for neurocognitive enhancement in surgeons, simply to outline the ethical debate that now needs to take place.

Section snippets

What Are the Potential Targets for Neurocognitive Enhancement in Surgeons?

There is an increasing array of pharmacological agents that have been demonstrated to affect “Executive Function,” the abilities that enable flexible, task-appropriate responses in the face of irrelevant competing inputs or more habitual but inappropriate response patterns [13]. This includes cognition, working memory, and attention, important functions for surgeons. Methylphenidate (Ritalin) is already prescribed to sufferers of attention-deficit hyperactivity disorder (ADHD) to improve

Ethical Considerations

We explore the ethical implications of neurocognitive enhancement of surgeons by considering the key areas summarized in Fig. 1.

Safety

When considering the potential risks involved in neurocognitive enhancement, it is essential to define the scale of intervention being discussed. While anything may become possible in the future, we find it hard to imagine surgeons considering invasive neurosurgical procedures to insert neural implants, just to gain a slight increase in capability. However, taking medication, either regularly or when needed, seems more plausible. We are aware that all medicines have side effects, from minor

Freedom of Choice

Both the United Kingdom and the United States are strongly libertarian, and many people will believe that if individuals are given adequate information about effects, and potential side effects, they should be free to make their own decisions. Should surgeons not be free to take medication because they feel it improves their technical and cognitive performance, even if they put themselves at a slight risk of adverse events? If we demonstrably improve a surgeon's performance, and the surgeon is

Character, Individuality, and Personhood

Within medical society, there is a “no pain, no gain” belief system, a belief that toil, struggle, and sacrifice are necessary for progression, and that hard work throughout the undergraduate and postgraduate years builds character. The ethical argument that follows is that “unnatural interventions” that ease the acquisition and retention of skill and knowledge undermine good character. Improving without working is cheating, and cheating cheapens us all [44]. These are valid concerns but in

Distributive Justice

If neurocognitive enhancers are not fairly distributed, they will provide an unfair advantage only for the rich or well connected. This may be particularly true at medical schools, where relatively wealthy undergraduates already tend to have certain advantages over their poorer colleagues; are we to add to these by making neurocognitive enhancement a preserve of the wealthy? Conversely, our society is full of inequality already and it may be no more grounds for prohibiting access to enhancement

Coercion and Regulation

If robust evidence demonstrating significant performance improvement following neurocognitive enhancement was forthcoming, surgeons may feel pressure from society to participate. It may go against certain medical principles to envisage coercion of an individual to take any drug, but this is not without similar precedents. Many societies strongly encourage participation in vaccination programs, on the advice of its physicians. Likewise it pressures (or forces via legislation) its clinicians to

Conclusions

The ethical debate surrounding neurocognitive enhancement of surgeons is emotive and multifaceted. Research evaluating the influence of novel stimulants on clinical performance has commenced and is likely to continue and expand. Patients are becoming increasingly aware of the performance variations between surgeons, and in years to come they may ask what forms of neurocognitive enhancement we do or do not practice, and on what evidence we make our choices. As the pharmaceutical industry forges

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