The current raging ethical debate in western health care is not how to save lives but how to end them. The controversial Liverpool Care Pathway in the UK, for example, where health care is nationalized, is really a death pathway. Unfortunately, half of the people on it are never told they are on it.

Canada has a different ethical problem; a whole bunch of citizens want to be smarter. It's been found that stimulants and neuropharmaceuticals prescribed to treat attention deficit disorder (ADD) really boost the concentration, memory, alertness and mood of people without ADD.

Such cognitive enhancement is bad, says  Dr. Eric Racine and his research team at the IRCM
the Canadian Medical Association Journal (CMAJ). They cite uncertain benefits and harms, and limited health care resources, all true when health care is paid for by everyone, just as trying to keep people alive can be costly. 

How prevalent is cognitive enhancement?  The number is unclear, so they cite a rather broad  1 to 11 percent estimate on university campuses and say the stimulants are associated with risks of dependence, cardiovascular problems, and psychosis, which won't make parents feel better about giving them to children with ADD either.

"Individuals take prescription stimulants to perform better in school or at work," says Racine, a Montréal neuroethics specialist and Director of the Neuroethics research unit at the IRCM. "However, because these drugs are available in Canada by prescription only, people must request them from their doctors. Physicians are thus important stakeholders in this debate, given the risks and regulations of prescription drugs and the potential for requests from patients for such cognitive enhancers."

"Current evidence has not shown that the desired benefits of enhanced mental performance are achieved with these substances," explains Cynthia Forlini, first author of the study and doctoral student in Dr. Racine's research unit. "With uncertain benefits and clear harms, it is difficult to support the notion that physicians should prescribe a medication to a healthy individual for enhancement purposes. Physicians in Canada provide prescriptions through a publicly-funded health care system with expanding demands for care. Prescribing cognitive enhancers may therefore not be an appropriate use of resources. The concern is that those who need the medication for health reasons but cannot afford it will be at a disadvantage."

 "An international bioethics discussion has surfaced on the ethics of cognitive enhancement and the role of physicians in prescribing stimulants to healthy people," concludes Racine. "We hope that our analysis prompts reflection in the Canadian medical community about these cognitive enhancers."