Who Should Get Alzheimer's Drugs?

If you live in the U.K. and have been diagnosed with early stage Alzheimer’s, you might not be able to get Alzheimer’s drugs, at least not through the country’s National Health Service.  Based on cost-benefit analyses, the government agency NICE (National Institute for Health and Clinical Excellence) recommended in 2006 that cholinesterase inhibitors (Aricept, Reminyl, Exelon) should be offered only to people in the moderate stages of Alzheimer’s.  The agency also recommended against prescribing these drugs for the cognitive symptoms of people with vascular dementia, and against prescribing memantine (Namenda, Ebixa) outside of clinical trials.  These recommendations are still being appealed.

NICE considers the cost/benefit ratio for all new drugs (not just Alzheimer’s drugs) in deciding what will be covered by the National Health Service.  The New York Times reports that other countries, including the U.S., are looking at NICE’s methods.

With this as background, a recent commentary in the journal Nature seems ironic.  In the commentary, seven co-authors say the use of Alzheimer’s medicines and other cognition-enhancing drugs by cognitively “normal” people could benefit both individuals and society.  They call for more research to understand the potential benefits and harm that could result.

The benefits of these drugs are described as “modest” for people with memory loss, and there aren’t many studies about how safe and effective they are for people without memory loss.  Even if future studies show positive results, I wonder whether it’s a good thing for people without cognitive impairment to use Alzheimer’s drugs.  What value will this provide to society?  Would I want to take these drugs?  If not, do I have to compete for jobs or resources with people whose brains are chemically enhanced? 

If we decide that cognitively normal people should be able to use these drugs, at least in certain situations, then we have to think about the financial cost.  The authors of the Nature commentary discuss this in terms of “fairness.”  They point out that cognitive enhancement might be affordable only for the rich, and suggest that in the example of testing for students, “one could mitigate this inequity by giving every exam-taker free access to cognitive enhancements.”  But somehow I can’t imagine high school teachers handing out cholinesterase inhibitors before an algebra test.

If other countries follow the U.K.’s lead and restrict reimbursement for Alzheimer’s medicines, the use of those drugs by people with memory loss who can’t otherwise afford them will decrease.  At the same time, the use of those drugs by cognitively normal people who CAN afford them may increase.  If Alzheimer’s medicines really help people perform better in school and at work, we may end up with a cognitively enhanced upper class and a cognitively challenged lower class.

Comments

[Gail Rae Hudson]

Really fascinating post, Mona. In the context of what I consider "the fact" that humans are always looking for ways to up their personal survival stakes, I'm not at all surprised that cognitive enhancement, for the rich, at least, at this time, is on the horizon. If cholinesterase inhibitors aren't found to do the trick, we can be sure that the interest in this concept will guarantee that something else will be found that will.
I am deeply concerned about this enhancement being added to the vagaries of class status. Even more of a reason for a global economic revolution that levels the playing field and allows us to think sanely about, you know, our perpetual concern with "what to do about" being human.