Note: Please click on the 
icons in the following text to view important questions and answers.
6.1. Case Study 1
May is a 25 year-old woman with relapsing-remitting multiple sclerosis (RRMS) who comes to your office for follow-up. She has been doing well on a disease modifying drug (DMD) for the last three years. At the age of 20, May had a bout of optic neuritis and the MRI of the brain and cervical spine showed demyelinating lesions consistent with the diagnosis of MS. With the administration of IV steroids, May recovered to baseline. Two years later May developed subtle weakness of the left arm associated with parasthesias. Her MRI was consistent with an MS flare and she received IV steroids with return to near baseline.
Currently, May is a second year medical student at your institution. On review, she tells
you that life is going well, but that she is studying for Step I of the USMLE (United
States Medical Licensing Exam) which is quite stressful. May tells you that she recently
read an article about Provigil (modafinil) being used to counteract the fatigue in MS, and
also learned that it is being used off label to improve concentration, attention, and
learning in sleep-deprived individuals. May asks you for a prescription to get through
the crunch time of studying for the boards.
Case discussion:
In this case, you have a long and established doctor and patient relationship with May. Given this, presenting the known risks and benefits of such a medication and coming to a decision together as a team may be the best approach. May has chosen a career that will be even more challenging by virtue of having a progressive neurological disease for which there is no cure. However, if certain symptoms can be lessened, one may argue in favor of prescribing the medication in accordance with the ethical principles of veracity, autonomy and beneficence.
6.2. Case Study 2
A long-time patient of yours has a son, Andrew, who is a law student interested in
international law. Andrew has been given what his parents view as an opportunity of a
lifetime, an internship with a very prestigious law firm in NYC to work on a big case in
Japan. If Andrew can impress the directors of the firm, especially those in Japan, his
parents are certain he will land a position at the firm after graduation. Although Andrew
took a few Japanese classes in college, he is more than a bit rusty. With just a few
months to prepare, your patient asks you if there are any medications on the market
that might hasten Andrew's mastery of the language and, if so, would you write a
prescription that he could deliver to Andrew that night? Since there is so much pressure
on Andrew, getting the prescription filled as quickly as possible would be very helpful to
him. You know there are data suggesting that amphetamines promote neural plasticity
and improve recovery in aphasic patients.
Case discussion:
In this case, you have no rapport with your patient's son Andrew who is not your patient at all. It would be unethical for you to prescribe a medication for someone whom you have never seen in consultation, simply as a personal favor. What if Andrew was to abuse the medication or something untoward was to happen? Who would be responsible for this adverse event? One option would be to refer Andrew to his general medical doctor with whom he has a relationship and together they can discuss the available options which may in turn result in a referral to a neurologist. Unfortunately, we do not know the long-term safety and efficacy of such drugs given that the off label and other novel uses of psychotropics to alter the neurobiological substrate of memory are experimental.
6.3. Other considerations based on these cases:
The contrast between these two cases highlights key points that were raised in the module, mainly the question of where treatment ends and enhancement begins. Patients with severely debilitating symptoms will often tolerate the side effects of drug treatment because improvements in symptoms outweigh the negative aspects, but what about when the medication is being prescribed to someone who is well? These are tough questions, which may not have "correct" answers given that the hypothesized effects have been extrapolated from different patient populations. To determine the safety and efficacy of these drugs, longitudinal studies involving a significant number of people are needed to specifically assess the risks and benefits so as to arm both physicians and patients with the knowledge they need to make informed decisions.
