Dan Larriviere

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.

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.

Terminating artificial nutrition and hydration in persistent vegetative state patients: Current and proposed state laws

This article presents an overview of current state law governing the right to terminate life-sustaining treatment in the United States as it relates to refusal of artificial nutrition and hydration (ANH) for patients who have been diagnosed as being in a persistent vegetative state (PVS). The article was stimulated by the efforts of Michael Schiavo, Terri Schiavo’s husband and legal guardian, to discontinue ANH for her, and the ensuing controversy. Like many other neurologists, lawyers, and ethicists, we assumed that the law governing withdrawal of ANH in patients diagnosed as being in a PVS had become relatively settled and that the prolonged litigation occurring in Florida was the exception rather than the rule.1,2 We reviewed state laws to ascertain whether this assumption was indeed accurate. End-of-life decision making is largely governed by state law, although the states’ prerogatives are subject to federal constitutional constraints ultimately enunciated by the US Supreme Court. Our analysis focuses mainly on patterns and variations in state statutes and does not encompass a comprehensive review of case law. Fortunately, in the present context, the statutes in most states provide fairly clear guidance to physicians and hospitals about whether ANH may be withdrawn from a patient in a PVS, and there is little need for resort to case law in most states to clarify their meaning. We used Lexis-Nexis and Westlaw legal databases to conduct a search of all state laws governing end-of-life decision making. We used the following search terms: permanent vegetative state , persistent vegetative state , artificial nutrition and hydration , advance directive , living will , health care power of attorney , coma , unconscious , terminally ill , terminal condition , surrogate , and proxy . We reviewed all statutes that contained any of the search terms and saved for analysis …

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.

Duty hours vs professional ethics ACGME rules create conflicts

In July 2003, the new duty hour requirements promulgated by the Accreditation Council for Graduate Medical Education (ACGME) went into effect. Broadly stated, the rules limit residents to 80 hours a week and no more than 24 hours on call at a time. They provide a 6-hour window for transfer of patient care and didactic activities for residents who are post-call. In addition, residents must not take call more than every three days and must have one day in seven free from patient-care responsibilities. The purpose of the rules is to improve patient safety by ensuring that residents will be well-rested and less likely to make mistakes when taking care of patients. The impetus for change is the increase in the severity of illness in patients admitted to the hospital, the increased public attention to the issue of medical errors in general, and the subsequent threat of federal legislation.1 In addition, the ACGME points to sleep studies that link sleep deprivation to declines in cognitive functioning as another reason for implementing the new rules.1 The relative strengths and weaknesses of the rules in improving patient outcomes are debated in other essays.2 My purpose here is to evaluate the new rules in light of their …

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.

Areas of persisting controversy in brain death

The tragic case of Jahi McMath reignited public controversy in the United States over the concept, practice, and legal status of brain death.1 Brain death is the familiar though misleading term for human death determination on the basis of irreversible cessation of the clinical functions of the brain. Burkle et al.2 have written an insightful analysis of the McMath case and provided a useful review of the salient ethical and legal issues that it raises. We fully endorse their comments and conclusions, which reflect the prevailing medical and legal standards of brain death in the United States. As supporters of brain death, our work has attempted to consolidate its conceptual, scientific, medical, and legal foundation. Like the senior author, Eelco Wijdicks, we have worked with the American Academy of Neurology to further brain death professional education and quality medical practice.

Pediatric neuroenhancement: Ethical, legal, social, and neurodevelopmental implicationsAuthor Response

The recent article on pediatric neuroenhancement is an excellent review of the ethical aspects of stimulant drug use.1 However, the authors may be off point. Most children initially receive stimulant medications from general pediatricians and family physicians who believe that they are treating attention deficit disorder (ADD). These physicians do not believe that they are prescribing drugs for neuroenhancement. It is rare for children taking these drugs to have received psychometric testing and these drugs are frequently started in elementary …

Regulating Physician Expert Witness Testimony

CI, 0.53-3.69). Both ORs were not statistically significant. We focused on their primary analysis so that we could compare our results with theirs. In our study, compared with women with no prevalent vertebral fracture, the adjusted OR of incident fracture with 1 prevalent vertebral fracture was 2.51 (95% CI, 1.84-3.43) and with 2 or more prevalent vertebral fractures was 5.22 (95% CI, 3.48-7.82). The reference by Samelson and Kiel to a 5-fold increased risk is to a subgroup analysis reported in the text showing that grade 2 (moderate or worse) prevalent fractures predicted grade 2 (moderate or worse) incident fractures. In their Framingham report (Table 4), there were 65 women who had a prevalent vertebral fracture at entry to the study; of those, 18 had an incident vertebral fracture. Information on the number of these women with a grade 2 prevalent fracture and a grade 2 incident fracture is not given, but the authors acknowledge that the sample size was small. Finally, these results were not directly comparable with the Study of Osteoporotic Fractures because we did not stratify by severity.