According to Indian American neurologist Dr Anjan Chatterjee of the Center for Cognitive Neuroscience, University of Pennsylvania, this is where American medicine may have finally met the great American dream of being happier, smarter, fitter.

"That is coming, and we need to know it´s coming," says Chatterjee, referring to what many consider the next frontier in specialty medicine where doctors not only try to protect ailing brains, but also may extend their efforts to normal brains. Chatterjee sees it as medicine that “makes bodies and brains function better by modulating motor, cognitive, and affective systems.”

Thus, Chatterjee speculates that the very same advances in neuroscience that are today yielding exciting treatments for neurologic diseases may have important implications for people without disease.

In a recent issue of Neurology, the scientific journal of the American Academy of Neurology, Chatterjee has raised important issues relevant to the practice of Cosmetic Neurology — the use of neurological treatments to improve the mood, cognition, attention, memory or motor skills of people who are not ill.

For example, while it is acknowledged that the purpose of medicine is to improve the quality of life of individuals who are sick, should medical knowledge be extended to enhance the physical and mental capacity of those who are already healthy? Or turn them into super humans. As Chatterjee says, "the questions I pose are: Can you be more than you can be? Should you?"

Chatterjee would like us to consider the following questions: 1. Would you take a medication with minimal side effects half an hour before language lessons if it meant that you would learn the language more quickly? 2. Would you give your child a medication with minimal side effects half an hour before piano lessons if it meant that they learned to play more expertly? 3. Would you pay more for flights whose pilots were taking a medication that made them react better in emergencies? How much more? 4. Would you want residents to take medications after nights on call that would make them less likely to make mistakes in caring for patients because of sleep deprivation? 5. Would you take a medicine that selectively dampened memories that are deeply disturbing? Slightly disturbing?

The ethical implications of brain-boosting drugs are enormous. Already, millions have seized the chance through cosmetic surgery to become more conventionally attractive; how many more would leap at the opportunity to become a little bit brainier? Mind medication is sure to be expensive, so will the rich be able to buy better brains? If soldiers perform better with certain drugs should the military force to take them? If some students can improve exam performance with a dose of this or a zap of that, would the test become unfair for others?

He assures you that such questions are not hypothetical. Not anymore. That’s because patients and advocacy groups encouraged by direct advertising to consumers are already raising such questions. If you are a doctor, asks Chatterjee, how will you respond to these “patients” when they turn to you as the gatekeeper in their pursuit of happiness?

Chatterjee observes that the distinction between treating disease and improving quality of life is echoed in discussions of therapy vs enhancement. Therapy is treating disease, whereas enhancement is improving normal abilities. Most people would probably agree that therapy is desirable. By contrast, enhancing normal abilities gives pause to many. In fact, Chatterjee hints that the U.S. military might already have a head start and speculates that “much research conducted on soldiers will not reach the public domain.”

Chatterjee is quick to acknowledge that the ethical concerns raised by cosmetic neurology are serious. “However”, he says, “in my view, hand-wringing of ethicists, journalists, and futurists is unlikely to have much of a restraining effect on its development. When faced with the analogous ethical concerns in other contexts, we collectively shrug our shoulders. Restraint by government regulation, journalistic consternation, and religious admonition are likely to be overwhelmed by a relatively unrestrained market and the military.

In America’s pursuit of happiness as an inalienable right, Chatterjee thinks that cosmetic neurology is inevitable. One plausible scenario that he envisions is that neurologists will become quality of life consultants. “Following the model of financial consultants, we could offer a menu of options, with the likely outcomes and the incumbent risks stated in generalities. The role would be to provide information while abrogating final responsibility for these decisions to patients.”

Not all of Chatterjee´s colleagues, though, agree that cosmetic neurology is inevitable, even if mind-improving drugs become safe and available.

In an accompanying editorial in the same issue of Neurology, Professor Richard Dees of the University of Rochester, NY, asks whether, if we are the sum of our experiences, we diminish ourselves by suppressing some of those experiences. In particular, if we have medicated suffering out of our own lives, how can we empathize with those who do feel pain?

Dr Stephen Hauser, a neurologist at the University of California, San Francisco, who also contributed an editorial to the Neurology debate, worries that a free-for-all in neurologic enhancements would extend to the unborn fetus. "If one could predict that an embryo has a 30% chance of developing multiple sclerosis, is termination ethical?" he asks. "Even more difficult, what about embryos in which the inherited component of intelligence falls at the low end of the parents´ gene pool?"

Dr Chatterjee calls on his colleagues to start thinking about these issues before someone else decides for them. But he believes any objections neurologists raise will be swept aside by a combination of capitalism, military expediency, and the personal vanity and competitiveness of the average human. Then there´s the socio-economic ethics issue: since cosmetic neurological drugs are unlikely to be paid for by the state, the prospect opens before us that rich people might become smarter and stronger than everybody else.

Chatterjee´s research is directed at understanding the architecture and neural bases for human cognition -- a field known as Cognitive Neuroscience. He uses experimental and neuro-imaging techniques to examine the neuro-psychological effects of brain damage. He believes that a clear understanding of cognitive systems and their breakdown is essential in educating patients and families and critical in designing rational treatment strategies.

In an earlier research work Chatterjee drew on nearly 50 research articles and books, and found that, “Artists with neuropsychological deficits do not necessarily produce art of lesser quality. Rather, their art may change in content or in style, sometimes in surprising and aesthetically pleasing ways.” By bringing scattered accounts into one body of neurological literature, Chatterjee raised intriguing themes relevant to the nature of artistic expression and proposed that art is worth considering as a neuropsychological probe.

Chatterjee has a B.A. in Philosophy from Haverford College and earned his M.D. from the University of Pennsylvania in 1985. His current research efforts are directed at the following:

* Language and meaning. How are language and space related? Do we use simple schematic structures across different cognitive domain?

* Visual, spatial and temporal processing. How does the brain direct attention in and to space and time? How do these processes influence consciousness?

* Visual aesthetics. Do fundamental principles drive visual aesthetics?

* Detailed investigation of rare or unique cases. How is it possible for a person to think that their limb has become "alien" as it performs purposeful acts without apparent volition? Why should a patient find it is easier to write and read mirrored than normally written words?

But with his most recent foray into the controversial issue of cosmetic neurology, Anjan Chatterjee’s friends have begun telling him he should “give up this stuff and open a brain spa.”

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