By Anna Cinelli, Donata Dettwiler, Igor Ranisavljevic
To which extent are doctors and their employers responsible to pursue the best possible care for the patients? Should they be required to take cognitive enhancers, even though this could mean putting their physical and mental integrity on the line?
The question of ensuring the best working conditions for doctors is part of a long-standing debate, which has economic, ethical and legal dimensions to it. It is estimated that 1/3 of deaths in the US are due to medical error (CNBC, 2018). Assuredly, the ways in which we can reduce sleep deprivation, which is an important factor in medical negligence, is part and parcel of ensuring the best working conditions for doctors, in their interest as well as of the patients.
Doctors and their responsibilities
Doctors have a moral and contractual duty towards their patient and have to be awake and focused on prolonged period (night shifts, long operations, etc.). Their jobs require to work for long shifts to assure that the patient receive the best possible care and that are no critical information loses in between the shifts. They have no room for errors, since other people’s lives depend on their actions. Moreover, doctors face strong liability issues during their careers, due to constant pressure of being sued by insurance companies and patients. In the case of healthcare professionals, they have the responsibility to provide patients with the best possible care, and cognitive functions improved could bring various benefits.
In 2012 the Academia of Medical Science published a report about “Human Enhancement and the Future of Work” and it concluded claiming that cognitive enhancers could possibly have a role in the professional life of some workers. Those drugs could be appropriate in cases where the need for those surgeons to be awake is crucial.
It can easily be argued: “why not just taking a strong cup of coffee?”. Caffeine is the most renowned natural cognitive enhancer, but its side effects, namely palpitations, tremor and headache are incompatible with the tasks of a surgeon. As opposed to coffee, using cognitive enhancers is still not widely approved by lay people (De Sio et al., 2014).
Historically, new measures were added to health professionals’ duties due to progresses in scientific and technological knowledge. One effective example is the introduction of basic antiseptic procedures, such as cleansing hands with carbolic acid, which nowadays are common. Originally, efficacy and risks of this practice where unknown, but today they are established practices that a doctor cannot refuse to follow (De Sio et al., 2014). In an article published in the Journal for Surgeon Research (Warren et al., 2009), the authors, licensed doctors, argued that the question of hand washing and sterility measures “are useful and warranted forms of coercion. What will our employers feel about a drug that makes us less prone to error, able to work longer hours, or to operate more efficiently?”.
Pharmacological Cognitive Enhancement
First of all, it’s necessary to provide a definition of pharmacological cognitive enhancement. They are chemical substances taken by a healthy individual which have reported to slightly increase some neurological functions, such as concentration, learning, wakefulness and memory.
Modafinil has been described as “the world’s first safe smart drug” (Harvard Business Review, 2016). It is a medication to treat excessive sleepiness due to narcolepsy, shift work sleep disorder, tested first on French soldiers during Gulf War (1991) without any authorisations. It’s very effective on the short-term but on the other hand, the possible reactions of Modafinil are nausea, vertigo and dizziness, and in long term it can cause dependency, memory damage and sleep pattern issues. Nevertheless, no accurate and definitive studies on the actual implications of the use of such drug have been studied on healthy adults. Nowadays, it’s mainly misused as a neuroenhancer by students and professionals because of its really strong effects – one pill will keep you awake for hours. The limitations of use are not homogenous around the world. As of now, the US legislation requires a prescription to use Modafinil. However, In the other countries, such as UK the substance is less regulated. The annual global share of the medication amounted to 700 million dollars in 2016.
Actors Mapping
Modafinil Regulation in the US
Off-label use of Modafinil and other neuroenhancers are already a reality for some medical interns (Elnicki, 2013). However, this use is not encouraged by the US governmental drug-regulating agency, the Federal Drug Administration (FDA). The FDA has in past chastised the company producing Modafinil for “false marketing”, arguing that it advertised the drug for insomnia or fatigue, even though the clinical studies approved by the FDA did not tackle specifically these symptoms (FDA, 2007). In this sense, it’s clear that there are struggles between institutional actors on what Modafinil should be used for and, especially, under what pretences it can be sold. Aside from these warnings, Modafinil is employed by a variety of actors to enhance their performance.
In 2012 the Academia of Medical Science published a report about “Human Enhancement and the Future of Work” and it concluded claiming that cognitive enhancers could possibly have a role in the professional life of some workers. Those drugs could be appropriate in cases where the need for those surgeons to be awake is crucial.
It can easily be argued: “why not just taking a strong cup of coffee?”. Caffeine is the most renowned natural cognitive enhancer, but its side effects, namely palpitations, tremor and headache are incompatible with the tasks of a surgeon.
Historically, new measures were added to health professionals’ duties due to progresses in scientific and technological knowledge. One effective example is the introduction of basic antiseptic procedures, such as cleansing hands with carbolic acid, which nowadays are common. Originally, efficacy and risks of this practice where unknown, but today they are established practices that a doctor cannot refuse to follow (De Sio et al., 2014). In an article published in the Journal for Surgeon Research (Warren et al., 2009), the authors, licensed doctors, argued that the question of hand washing and sterility measures “are useful and warranted forms of coercion. What will our employers feel about a drug that makes us less prone to error, able to work longer hours, or to operate more efficiently?”.
Comparison with Modafinil’s use in the Air Force
Modafinil is reportedly used to allow longer working, greater concentration while studying, and to treat the effects of jet-lag. The off-label use of modafinil is not limited to private individuals: some Air Forces has approved the use of modafinil for pilots involved in certain aviation operations.
Army has a long history of supplying legal and illegal drugs to soldiers. A specific case: the Times of India in 2016 describe the new weapon of The Indian Air Force: innocuous looking tablets called “Go/No Go” pills. Go pills, namely Modafinil, are taken by pilots before their operations, whereas No Go pills have the opposite effects on human body are taken after the shift. Employers provide those drugs to their pilots, so could it be that in the future hospitals as well be responsible for ensuring the best care to patients giving enhancers to their doctors?
Legal dimension
This topic is increasingly been debated outside of medical circles, given that the controversy has a legal dimension as well. As some have pointed out, cognitive enhancers may lead to new professional duties (De Sio et al., 2014). Some lawmakers argue that the use of neurotechnologies, such as Modafinil, threaten the so-called Cognitive Liberty of individuals. Cognitive Liberty has been developed, among others, by Bublitz (2014), a law scholar, as a principle referring to the right to mental self-determination. As a legal concept, however, it has not yet been recognized by US Courts. Requiring doctors to take Modafinil or other pharmaceutical cognitive enhancers questions the freedom of thought and the the right of doctors to refuse such enhancers. Some scholars believe that the circulation and use of Modafinil for healthy individuals does not necessitate “new laws or regulatory agencies” (Greely et al., 2008) in order to face the ethical and legal concerns of such debates.
Future scenarios
This controversy relates to a broader phenomenon of medicalisation of sleep in our societies, which further blurs the difference between treatment and enhancement. We may ask ourselves if sleep may not become entirely obsolete in the future (Williams et al., 2008). Will our whole society be overworked and will the use of drugs to keep up be necessary? Or will technology replace humans in high responsibility jobs so the use of these drugs will become unnecessary?
References
J.C. BUBLITZ, My Mind is Mine?! Cognitive Liberty as a Legal Concept, in E. HILDT and A. FRANCKE (ed.), Cognitive Enhancement, New York, 2013, pp 233-264.
M. DAVIES, Is it Clever for Doctors to Take Smart Drugs?, The British Medical Journal, 2016.
F.S. DE SIO, N. FAULMÜLLER, N. A. VINCENT, How cognitive enhancement can change our duties, Front. Syst. Neurosci., 2014, 8(131), pp. 1-4.
D.M. ELNICKI, Cognitive enhancement drug use among medical students and concerns about medical student well-being, J. General Intern. Med., 2013, 28, pp. 984-985.
H. GREELY, B. SAHAKIAN, J. HARRIS, R.C. KESSLER, M. GAZZANIGA, P. CAMBELL, Towards responsible use of cognitive-enhancing drugs by the healthy, Nature, 2008, 456, pp. 702-705
I. GOLD and H. MASLEN, Must the Surgeon Take the Pill? Negligence Duty in the Context of the Cognitive Enhancement, The Modern Law Review, 2014.
G.G. ENCK, Pharmaceutical enhancement and Medical Professionals, Medicine, Health Care and Philosophy, 2014, 17(1):23-28.
Ray SIPHERD, The third-leading cause of death in US most doctors don’t want you to know about, CNBC, 2018, Feb 22. [Online] Retrieved from: https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html
O.J. WARREN, D. R. LEFF, T. ATHANASIOU, C. KENNARD and A. DARZI, The neurocognitive enhancement of surgeons: an ethical perspective, Journal of Surgical Research 167, 2009, pp. 167-172.
S.J. WILLIAMS, C. SEALE and S. BODEN, Waking up to sleepiness: Modafinil, the media and the pharmaceuticalisation of everyday/night life. Sociology of Health and Illness, 2008, 30(6), pp. 839–855.
Wikipedia, Modafinil, (https://fr.wikipedia.org/wiki/Modafinil), Accessed March, 2019