editorial comment Cosmetic neurology? Even more fashionable than paraphernalia!

In the future, reality shows may have names such as "Extreme Makeover: Brain Edition" or "Sharp Eye for the Dumb Guy."

At the beginning of each episode, viewers could learn about one hapless soul's lifelong struggles with algebra and another's desire to not be a worrywart. By the end of the hour, the transformed contestants would be winning chess matches and prancing carefree through fields of daisies. Don't check the TV listings just yet, but the idea is not all fantasy.

Some neurologists have recently wondered whether their field is the next frontier in elective medicine. The specialty now tries to protect ailing brains from conditions such as Parkinson's disease or migraine headaches. But doctors' efforts may one day extend to normal brains.

"This is coming, and we need to know it's coming," says Dr. Anjan Chatterjee of the University of Pennsylvania.

There's even a name for the field: cosmetic neurology.

As he envisions it, cosmetic neurology could one day mean not just sharpening intelligence, but also elevating other dictates of the brain - reflexes, attention, mood and memory. Studying for the SAT? Take this drug to retain more of those pesky facts. About to report for duty at the fire station? These pills will improve your reflexes. Here's the 800 number. Ask your doctor.

These are not just theoretical musings. Last month in the journal Neurology, Chatterjee pointed out that drugs already exist that may have many of these effects. In one study, for example, emergency room patients given a memory-altering drug appeared to be spared some symptoms of post-traumatic stress. Another small study of pilots in flight simulators suggested that those taking Alzheimer's disease medications performed better, particularly under emergency conditions.

Chatterjee reserves opinion but says the idea speaks to the basic purpose of medical practice.

"I'm not arguing that this is a bad thing, and I'm not arguing it's a good thing." Before doctors are caught by surprise, he says, they need to be prepared. "What I'm hoping to do with this is get people talking."

They are. Since the journal's publication, he has fielded steady e-mails. Some neurologists say they've already had patients asking about such medications for the mind.

Not all of Chatterjee's colleagues, though, agree that cosmetic neurology is inevitable, even if mind-improving drugs become safe and available. "There are certainly pressures that are going to push us that way," says Dr. Richard Dees of the University of Rochester. Doctors have the power, however, to shape the future of their profession regardless.

Writing in the journal, Dees argues "as neurologists and as citizens, we can collectively control our own destinies, if we choose and if we have the will to act."

Another of his colleagues has a different take. Dr. Stephen Hauser of the University of California, San Francisco, wrote that "advances in neuroscience carry with them the likelihood, intended or otherwise, of medical applications that go well beyond the traditional goals to prevent, diagnose and treat disease."

Few specialties know this as well as plastic surgeons. Before there was "Nip/Tuck" and Michael Jackson's nose, plastic surgeons were rebuilding war-mangled bodies. As safety improved and public demand for cosmetic surgery grew, so did the number of cosmetic surgeons.

"You've always had a dilemma and a schism," says Dr. Robert Goldwyn, who has edited the Journal of Plastic and Reconstructive Surgery, the field's premier journal, for a quarter-century. In fact, some plastic surgeons now wonder whether their profession - under financial and public pressures - leans too far toward cosmetic surgery. And he has these words of caution for his colleagues who concentrate on the brain: "The minute technology comes along, it will be used," he says. "If doctors won't do it, other people will do it."

There are other instances of doctor-provided enhancements beyond plastic surgery, says Thomas Murray, president of The Hastings Center, a Garrison, N.Y.-based bioethics research institute. Synthetic growth hormone was originally developed to help children with severe hormone deficiencies. But some parents have asked doctors to give it because their children are simply at the low end of the normal-height bell curve. In response, endocrinologists have tried to develop strict guidelines for its use.

"The thing about surgical enhancement is we think we can more or less understand the risks," Dr. Murray says. "With drugs it gets more complicated."

Mental enhancement with drugs is not itself unethical, he says - a cup of coffee, after all, heightens alertness beyond a natural state. Few people object to caffeine, however, because it is considered safe, is inexpensive and is available to almost everyone.

But other drugs might not be so clear. "There are major safety concerns," Murray said. For example, a person's personality is a blend of all traits, yet no one knows whether a drug that distorts one mental function would diminish another.

In his editorial, Chatterjee also raised questions about whether cosmetic neurology might lead to coercion in certain professions. If a drug improved the emergency reaction of pilots, would they then be forced to take it? Would you pay more for a flight knowing the pilots took the drug?

These and other questions are those that neurologists should be asking themselves now, Murray said, before reality, if not reality television, takes them by surprise. The growth hormone story, he says, demonstrates that physicians can set standards, regardless of where public momentum pushes them.

Murray applauds the neurologists for raising the issue. "It alerts the profession that it needs to think about it."

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