 Our next presenter will be Margaret Moon, who is an Associate Professor of General Pediatrics and Adolescent Medicine at Hopkins, where she's a Freeman family scholar in clinical ethics. And she's going to talk to us on enhancements versus treatments, boundaries, and decisions. And I'm glad we have the title here because it's different from what's in your brochure. Please join me in welcoming Maggie, please. Thank you very much. Yes, I change. I'm a veteran fiddler. I can't leave a set of slides alone for the whole day, so I did change several things and I appreciate the ability to have this up here. And again, I want to thank the McLean's, and I want to thank Mark, and I want to thank everybody who participated in these ethics sort of get-togethers over the years. It's always been a source of wonder and support for me in the work that I do. So I want to talk today about enhancements and treatments. And this is related to the work that I do at Hopkins, and I have no financial disclosures. I am going to talk about off-label drug use, but absolutely not encourage it here. These are all the organizations with which I work, and all of these organizations have something to do with the work that I'm going to talk about today. But mostly I want to explain that my work at Hopkins is mostly involved with teaching ethics and teaching ethics to physicians who are often very much morally sensitive and morally aware, but not particularly interested in ethics. And so the goal of much of my work is to help practicing physicians work out everyday clinical ethics problems in a way that's morally justifiable without insisting that they become ethics fellows. So this question comes up. I think that enhancements are becoming more and more a part of the way we think about ourselves as human beings, and I'm worried that the pressure about enhancements is going to have a big impact on practicing clinicians, and it's confusing. It's confusing to me, so I'm presenting this as an idea hoping that this group can help me think through it and see if we can come up with something that will assist practicing physicians in making ethically justifiable decisions. So several questions come up to me. What are the actual boundaries between treatment and enhancement in medicine? And I'm focusing very much on medically mediated or surgically mediated enhancements. As a mother of two children, I've spent a huge amount of time enhancing my children's lives. I'm talking very narrowly about medically or surgically mediated enhancements, the ones that need a physician to write a prescription or do a procedure. So do the boundaries matter if we can find them? And then what are the ethical dilemmas inherent in the use of enhancements, especially because I'm a pediatrician because I think it's more complicated in pediatrics, what are the implications for children? And then the goal would be to develop a framework to help practicing physicians consider the use of enhancements in clinical practice. And I think that if we do this right, we'll center that framework on our own understanding of the goals of medicine. That's my hope. To do it, I want to just present three cases very quickly to help us all sort of think about this the same way. So here's the first one, a 16-year-old girl in your practice. She's worked very hard to overcome dyslexia and early school failure. She's done incredibly well. She's on her way to university and you'll probably have a chance to some of the top tier universities. She's ready to take the SAT and the ACT next month. She's been studying doing well, but she feels the need to work a bit harder. Her friends tell her that Adderall will help. They've commented that this taking Adderall makes them feel focused and capable of studying longer and harder. She has no history of ADHD. Her parents are supportive and they have no concerns that she would abuse the medication. Would you be willing to prescribe a trial of stimulant medication for this young lady? Second case is a healthy woman, 30 years old, wants a prescription for an SSRI. She's no history of depression. She screams negative for depression today. She agrees that she feels generally well and emotionally stable, but she's read and heard that SSRIs can increase an overall sense of well-being even for people without depression. She has no medical contraindications. Would you prescribe? And this one was something that really fascinated me. There was a study several years ago about Aerocept or Dineppazil, developed for Alzheimer's disease. It showed in some randomized clinical trials that it improved the performance of airline pilots in flight simulators. Airline X wants to encourage its pilots who fly the short hop routes, the ones that make us all really nervous, the ones with frequent takeoffs and landings to take Dineppazil to enhance improvement at the highest risk times of flight. They'll offer a salary stipend. Furthermore the airline wants to advertise that their pilots are enhancing their cognitive capacity in the interest of passenger safety. What are the concerns and would you be more willing to fly that airline? So I think these are real questions. I can sort of feel these things coming up in my own clinical arena and maybe in yours. So to think about what I mean by enhancements versus treatments, the key points about enhancements is that they're designed to improve capability unrelated to an identified disease or disorder. So the idea is that there's something that will change the biology or psychology, increasing the person's chance of leading a good life. As opposed to the notion of treatment, which is designed to treat an identified disorder. Some examples of medically or surgically mediated enhancements, you know cosmetic surgery in teens is always something that makes us sort of check ourselves and wonder what we're doing. The most common cosmetic surgery in people under the age of 18 is otoplasty, so getting your big ears pinned back a little bit. Rhinoplasty or the famous nose job that people want to get in their summer before college. Breast enhancements or breast reductions, sometimes those are for medically indicated disorders. Sometimes not. Blepharoplasty or specifically the double eyelid surgery that is apparently more common in Asian young Asian women. And labiaplasty is something that sort of entered the media discussion lately about girls being unsatisfied with the design of their vaginal architecture, wanting to change the way that part of their body looks unusual, but I put it in there because it's weird. What's not weird in here is some other ideas like you know our vaccines enhancements and how can we add vaccines to our understanding of what we mean by enhancements versus therapies. But some other ones are cosmetic dentistry, cosmetic endocrinology. The FDA has approved growth hormone for kids who are in the third percentile of height, so it's a normal short stature, and cosmetic psychiatry and that's probably one of the most interesting arenas because they're such a rapidly expanding toolkit. Here's some examples. So cosmetic psychiatries identified as the enhancement of cognitive, behavioral, emotional processes in persons who don't suffer from illness or identified disease. So beta blockers for anxiety, SSRIs in the absence of depression, a stimulant like Ritalin, which is a Schedule II drug as a study aid, modafinil as a performance booster. And then this is actually not medically mediated because the whole notion of nootropics or smart drugs, a growing focus of social media and popular media. I've seen my sons are young adults now, and I was asking one of them about there was a recent interesting book review in the New York Times about ADHD nation, which is an interesting book, and I was talking to my older son about sort of how much people are using stimulant medications and really overusing to the point of actually becoming quite ill. And as usual, he said, Mom, you are so behind the times. 80 stimulant medications are out now, and now it's micro dose LSD to enhance creativity and productivity. I thought, you're nuts. I thought, that's not true. And then I looked it up and it's amazing the information you can get on the web about how to do this. So we are all behind the times. But none of this is actually all that new. So this is from Brave New World. If ever by some unlucky chance, anything unpleasant should somehow happen, there's always soma to calm your anger, to reconcile you to your enemies, to make you patient and long suffering. I think I need some. In the past, you could only accomplish these things by making a great effort and after years of hard moral training. It's amazing. It's amazing to think about this now. Okay, so I'm thinking about what do we want to do? How do I want to help practicing physicians make sense of some of these issues around enhancements? So I think if I'm trying to come up for a framework within which we can justify or question the justification of the use of enhancement treatments or enhancement therapies, here's a set of questions I've come up with. The first one, does this use of technology fit within the established goals of medical care? Or if not directly within the established goals of medical care, is it close enough? Or does it fit within some other well-established social goal? Next question, is it actually enhancement or treatment? Can you identify which camp it falls into? Is there a disease and a disorder? If so, what is it? Can you identify it? Does the use of this technology fit within the established standards of the profession? Are the risks and benefits well-balanced? And are you clear about the evidence base? And the last one, are there other important ethical considerations? And I highlighted social justice here because I think this one troubles me. When I teach students about the notion of rationing at the bedside, which medical students these days are so ready to do, they feel like it's their job, I make the point that rationing at the bedside is probably contrary to what you've agreed to do as a physician. Your job as a doc is to promote the well-being of the patient in front of you, to do your best within the system for the patient in front of you. But I realize that when I think about enhancements, the notion of social justice pushes me in exactly the other direction. I really think that we should think twice about using enhancements because it really makes the playing field even more unlevel for those who don't have the wherewithal or the wisdom to ask for them. So it challenges me, and I'm not sure how I can be consistent talking about both scenarios. The next question is about the goals of medicine. So do we really understand, and certainly the bigger question, do we agree on what the goals of medicine are? So there are hard line constructions of the goal of medicine, which means, which look at health as freedom from disease, really focusing on the notion of pathology. So this is Dr. Pellegrino, the primary intention of the use of biotechnology is to treat physical or mental disease, really a sincere focus on pathology. Norm Daniels, the goal of health care is to restore to the patient the range of opportunities that would have been available without the disease or disorder. Again, the focus is on disease, disorder, remedying, bringing people back to normal. A more expansive broader construction of the goals of medicine is health as physical, mental, and social well-being. The goal of medicine is to promote and protect all dimensions. So you see in that expansive construction, really the door is wide open to accepting as the role of a physician the prescription of enhancements. The next one, can we identify whether particular use of technology is treatment or enhancement? So there's several problems in this one. One of them is that we have a very malleable border between health and illness. The hard line construction these days is hard to hold because we're not really sure what we mean as a society by health and illness, and that's actually not really a medical definition. It's really sort of becomes a societal definition. There are very important social and technological influences on our feelings about the border between health and illness. There's also the problem of diagnostic imprecision. We are often wrong and we diagnose a disorder or say that there's no disorder. And there's also an important problem of a lag translating science to medicine. So there may be a disorder. We have enough data. We're getting data. We're starting to define it. But it takes a long time for something to hit the ICD-10 or the DSM-5 as a real disorder. Probably the most important one to me, I think, is that the problem of suffering, whether without an established diagnosis, suffering matters. And I get that the role of a doctor is to ease suffering. So the problem, though, is this suffering related to a disorder that I can justify using medication for? Or is it something else altogether? And the very coercive nature of social norms can easily create pathology, right? So the notion that a young woman would want to get her nose fixed before she goes away to college has a whole lot to do with social pressures. Finally, I love this story about we also are challenged because there are always drugs looking often successfully for a disease. And I love this story about Latisse, which was a drug that was initially developed, I think, for glaucoma. And it didn't work very well for that. But it worked very well in enhancing the thickness of your eyelashes. So all of a sudden, a pop this diagnosis, eyelash hypotricosis. And if it happens, we have a drug to treat it. So I think that's a cautionary tale. Happily, this drug turned out also to stain your eyelids so it became less popular. Brooks Shields, this was Brooks Shields advertising this drug for several years until, I think, finally people gave up on it. But the other one I really like is this notion of jet lag disorder or desynchronosis, for which you can get treatment with Medaphanel or ProVigil. And I've always thought that jet lag is sort of the price you pay for adjunting off to Paris. Turns out you can get a disorder and you can get treated for it with Medaphanel. Next question, does this use of the technology fit within the standards of the profession? And here we stumble again. It's difficult sometimes for any profession to actually set very clear standards. But even within medicine generally, there was a charter on professionalism published in 2002. Key values of the charter on medical professionalism includes, number one, the primacy of patient welfare. Number three, social justice. So remember when I said that social justice was my concern here? Even the charter on professionalism sets us up for an important conflict between professional obligations. Promoting the welfare of the patient in front of me and trying to protect social justice really puts me at odds with myself, especially with regard to something like an enhancement. Are we assessing the risks and benefits of enhancing technologies effectively? This is incredibly difficult because the database is evolving so rapidly. It's incredibly difficult to keep up. There's constant development of new technologies. And the fact that the notion of enhancements and new atropic drugs and cosmetic psychiatry, et cetera, very, very heavy presence in popular media. I love this in PLOS One in November 2011, an article saying, smart drugs are as common as coffee. And the articles in the popular press about smart drugs, they often portray their use as very common. And they're often likely to mention benefits without the risks. So the popular media really puts us in a bind here. And here's a result, I mean, an article from Nature News saying that 20% of nature readers who responded to a study said they had used enhancers, riddle-in beta blockers, or ProVigil. So we're doing it too, right? So I cannot call the head of black here. The other problem with risks and benefits is that pharma is always a step ahead of us. Pharma is incredibly good at direct-to-consumer marketing, so my patients know about enhancement treatments and they are enhancing therapies. And they know to ask me for them specifically. Also, pharma is adept, as you all know, at manipulating the academic literature to really give us information saying that these drugs are safe, effective, and ethically justifiable. I think I was struck. I spent some time looking at articles about ADHD meds for adults and checking to see who the authors were. And even though they always had an academic first and last author, on almost every article I looked at, the middle author was somebody worked for one of the drug companies, one of the big drug companies that makes these medications. It's very clear that we're always being outdone by pharma and it makes this very difficult for us. Okay, so based on those things, my very tentative recommendations, and I would love to hear comments about this, is this would be recommendations for, again, practicing clinicians who are not ethicists but who are morally aware and trying to make good choices in a complicated arena. The first one is to develop an informed personal awareness of the goals of medicine and professional values. I don't think we're at a place where we can tell people clearly what the goals of medicine are. But I do think we can expect that physicians should work to develop one that is morally coherent and reflects their personal values. The second recommendation is that every time a patient presents with a question that feels like it might be a request for an enhancement, assess the disease, assess whether there is a disorder and understand the desire for this particular enhancement. Sometimes that request itself may lead to a diagnosis like body dysmorphic disorder or anxiety or depression that actually is something you should treat. And the request for enhancement makes you ask about a question about a different diagnosis. Determine whether the request fits within your sense of the goals of medicine, close enough, sort of the shadowy edge of the goals of medicine, or outside the goals of medicine but within acceptable societal goals like promoting social justice. And remember always that it's just medicine. This is not different than other aspects of medicine. It's imperative that if you're considering enhancement treatments, therapies, that you attend to autonomy, you attend to safety and efficacy concerns, look at alternative therapies, think about justice as fairness and make sure that the doctor-patient relationship is strong and enduring. That's the end. And I wanna thank very much the AAP Committee on Bioethics who I've talked to about this work. My colleagues in the Berman Institute of Bioethics and the American Academy of Child and Adolescent Psychiatry, Michelle Goldsmith and Mary Lindell have both participated in this conversation. Thank you very much. I'm happy to answer questions. Fascinating, fascinating paper. And I should disclose I just had a cup of black coffee which may enhance my questions. But you didn't ask anybody to prescribe it for you, right? True. And the micro dose LSD sounds fascinating too but it's a child of the 60s talking. One of the things you alluded to but I think is important is that some of the enhancements you're talking about are basically part of a zero-sum game. The girl in number one who wants to get into the Ivy League College, somebody else won't. You wanna fly the plane, this airlines somebody else won't, and particularly the issue of height. And I wrote a paper a while back called Tall Girls because before we had growth hormone therapy which makes the boys taller, we had estrogen therapy which makes the girls shorter. The thing about height is if you believe that at the extremes, let's say the two standard deviations in one direction or another, there's a problem. Guess what? We take the bottom 5% and move them up, there's still a bottom 5%. We take the top 5% of girls and move them down, there's still a top 5%. So it seems to me that there are some enhancements and this gets to your social justice issue that are basically redistributing in a zero-sum game and it seems to me those are fundamentally different than something that just makes me feel better but doesn't make me necessarily feel better at the risk of somebody else feeling worse. Yes, that's a really important point you're making and I think I tried to capture that a little bit in this discussion of social justice in this realm versus my sense of telling people to avoid rationing at the bedside with other medical technologies but I sort of want people to ration at the bedside here because I'm worried that these enhancements will just move the goalposts, right? And just make the world even more unfair than it currently is. So I think this is one that we need to struggle with. Yes? Scott Grant, University of Chicago, enjoy your talk. Thank you. I first would say that there's been a lot written on this topic by people like Eric Perens on surgically shaping children and Julian Savilecu on human enhancement and also a lot written on the question of height enhancement and people who don't have human growth hormone deficiency. Yes. I guess that when I think about this, I think that there's always gonna be sort of two camps. There's going to be the purists who think you should only treat medical diseases and disorders and then people who are sort of more promoters of whatever the best medical technology has to offer should be available to the masses as long as it's distributed in a just manner. And I think that given, again, something you pointed out which is that the DSM changes over time in terms of what's considered disease and what's not, how do you reconcile those two camps? Right, so I sort of laid those camps out, I think, as hardline constructions of the goals of medicine and expansive constructions of the goals of medicine. I think that's sort of parallel to what you're saying. I don't think I can reconcile them. So the point of this is to offer practicing physicians a framework within which they can make decisions about enhancements based on their own sense of the goals of medicine. So I don't think those, I think it's very difficult to reconcile those two camps. I actually can't do it. I don't think we should try to do it. I think that either as a society, we need to come up with a broad definition of the goals of medicine and apply it. Or we should ask practicing physicians to work hard to come up with their own that's morally coherent and apply it effectively. Elizabeth, you keep it brief and good? Brief and good, I don't know. I mean, if you just brief. I'm Elizabeth, I'm a practicing psychiatrist. I treat emerging adults, so this comes up in my practice often. Yes. I guess one comment that I have to make, which is just that I think we, as a medical community, like to point out that DSM changes, and it does. But so do the guidelines for hypertension and diabetes. Yes. And that doesn't make us say that those diseases are nonetheless real. And so when we're thinking about cosmetic psychiatry, for example, I think it's really imperative to separate cosmetic psychiatry or enhancements from, for example, self-medication, people taking drugs that they have not been prescribed but that are out on the street. And also from what it is to have real disorders as we currently define them, which in psychiatry is ever changing as it is in the rest of medicine. The other two principles that I wanted to highlight were the principles both of justice, not quite as you're thinking of it, but in terms of the community standards and what it does when we provide enhancements to people that they don't require for disease. When we put things like stimulants into the patient population, those are non-trivial drugs that are shared with great ease and can be in fact quite, quite harmful. So in terms of both justice and non-maleficence, I think we have to really put those standards really at the top of what we consider when we're thinking about enhancements in general. Thank you, that's a really wonderful point. And I raised that issue when I spoke with the American Academy of Child and Adolescent Psych about this. And it was interesting that many members of the audience reminded me that the DSM is only guidance that's not necessarily definitions. So within the DSM, psychiatrists or end practicing physicians anywhere are very free to sort of make a decision about whether something is a disorder or not. So I think it gets back to the same basic idea that we have to have our own very internal but hopefully coherent approach to these things because I think we're stuck. Now remember, I'm really focusing on medically mediated enhancements. And I understand what you're saying that stimulant medications, physicians write prescriptions and have no idea where those drugs are going, right? And I think that's a big problem. I think there is some place we could actually probably raise our own bar of making sure that we understand what's happening. Thank you very much. It was a great question. Thank you. Please join me.