To heal, or to enhance? Medicine grapples with "cosmetic neurology"

New treatments intended to heal the sick also may help the healthy flourish. Where should doctors draw the line?

By Kevin B. O'Reilly, AMNews staff. Aug. 28, 2006.

Lecturing a group of students last fall, Martha J. Farah, PhD, commented that there was probably someone in the audience making use of modafinil, approved to treat narcolepsy but mostly prescribed off-label to long-haul truckers, jet-lagged ocean hoppers and anyone else too busy to sleep.

"You were right about that!" said a graduate student who approached Dr. Farah, director of the University of Pennsylvania's Center for Cognitive Neuroscience, after the talk. Once a week, said the student, who is also a teaching assistant, he would find himself falling behind on answering e-mail and grading work. With modafinil, he could stay up all night and still work through the next day.

Dr. Farah's observation was far from a shot in the dark. Increasingly, students at highly competitive universities such as Penn are using modafinil, or stimulants intended to treat attention-deficit/hyperactivity disorder, to enhance their already considerable abilities. Some students are asking doctors for these so-called smart pills, though most obtain them illegally from campus dealers.

College kids aren't alone in looking to doctors to do more than just cure their ills. Middle-aged men ask physicians for testosterone boosters. Some adults even seek growth hormones, one of the engines that allegedly helped Barry Bonds overtake Babe Ruth on baseball's all-time home run list.

But should doctors say yes when patients ask for enhancement instead of healing?

It's a question that medicine has grappled with on a smaller scale for years. Cosmetic surgery posed similar questions decades ago and continues to outpace medically necessary reconstructive surgeries. Peter Kramer's 1993 book, Listening to Prozac, alerted the nation to patients who sought to feel "better than well." And it didn't take long after Viagra's 1998 approval before some normally functioning men began using the drug to enhance their sexual experiences.