Neuroenhancement, or “cosmetic neurology,” is the use of neurological interventions to improve cognition or affective functioning in healthy individuals. The most popular form of neuroenhancement is nootropics-pharmacologic substances that enhance cognitive performance in areas such as memory, creativity, motivation, and attention-despite their application to non-diseased individuals remaining controversial. This discussion seeks to provide an overview of the current interventions available and their usage in both healthy individuals and those with neurological diseases, followed by an exploration of their ethical implications and the ambiguity between treatment and enhancement.
Neuroenhancement comes in many forms. Non-pharmacologic methods include both transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), which modulate cortical excitability using magnetic fields and electric currents, respectively. While only an FDA-approved treatment for major depressive disorder, TMS has shown moderate evidence in improving working memory, attention, and executive functioning, but effects remain highly variable and relatively task-specific. tDCS currently has no FDA approval but some early studies show increased memory and learning benefits whereas more recent studies describe very small effect sizes, if any. Even the effectiveness of widely accepted cognitive-enhancing medications such as methylphenidate and modafinil remains debated, with critics questioning their true benefits, as the supporting data often rely on subjective survey responses.
It is clear that although neuroenhancement suggests beneficial outcomes, the strength of these results remains tenuous, and its wider application introduces a number of ethical considerations. Despite this, the use of nootropics continues to rise in the American population as people in various fields seek to improve cognitive function. In particular, the largest consumers are university students, and one multi-institutional census approximated that 18% of medical students reported using prescription psychostimulants at least once in their lifetime. This introduces the dilemma of what amount of neuroenhancement is considered unfair, and whether its use should be allowed in academic competition. What about in fields such as aviation or the military, where an increase in alertness or concentration could provide benefit beyond the individual and potentially save lives? Conversely, with supplement contamination, limited regulation, and negative health consequences as potential dangers, should their use be explored at all in individuals whose alternative is normal physical health? The answers remain unclear, but this discussion aims to foster a thoughtful dialogue regarding the ethical boundaries of cognitive enhancement and its implications for individuals and society.
Ethical Considerations of AI Use in Manuscripts
Author: Ryan Chen, MS3
Artificial intelligence (AI) has become more accessible, widespread, and varied in its application over the past decade. However, large language models (LLMs) such as Chatgpt and Deepseek are still imperfect tools constantly under development. One dilemma that warrants consideration is the degree to which AI ought to be incorporated into research publication.
Traditionally, manuscripts are original works of the authors, with references obtained through established research databases. Large language models are capable of both writing publication material and procuring scientific references, albeit with unreliable authenticity. How much of a scientific paper, then, is acceptable to be written by AI?
The results section should remain unaltered by AI to preserve the originality of the author’s work, and the methods section, regardless of AI input, should truthfully reflect the study’s procedure. However, appropriate uses of AI in the introduction and discussion aren’t as clear. Relying on AI to construct an introduction casts doubt on citation credibility, literature review comprehensiveness, and correct interpretation of prior papers. Incorporating AI into a discussion brings into question the interpretation of results and the conclusions drawn.
One solution is to limit AI use to editing human-written content, which is a commonplace application of LLMs. Yet, the vast capabilities of these LLMs means that editing can vary anywhere from synonym replacement to complete paragraph rewriting. It is therefore best to be transparent about AI modifications by fully describing and disclosing its use in publications.
As AI becomes more prevalent, it is inevitable that medical students will interact with these technologies in some capacity, especially since medical students tend to conduct research and seek publication. It is therefore important for medical students to recognize and discuss the ethical nuances of using these developing technologies to learn, conduct research, and advance careers. Questions around transparency and degree of AI use need to be addressed in the early stages of AI implementation to ensure proper ethical adoption of the technology.
Beyond the Scan: Ethical Challenges of Incidental Findings in Radiology Research
Author: Andrew Sasser, MS1
Incidental findings—unexpected abnormalities discovered unintentionally during imaging—pose a significant ethical challenge in radiology research. With the widespread increase in medical imaging, incidental findings—those outside the primary purpose of obtaining imaging such as CT or MRI, but which may have substantial implications for a patient’s future health—are becoming increasingly common. 1,2
A critical ethical issue for researchers is the duty to actively search for incidental findings. One utilitarian argument suggests that, given limited research funding and the narrow scope of imaging studies, it is more valuable to prioritize the creation of generalizable knowledge rather than divert resources toward the pursuit of potentially insignificant secondary findings³. Another perspective emphasizes informed consent; researchers should, ideally, predefine a list of possible secondary findings and communicate this information to participants prior to study enrollment. In contrast, some argue from the principle of beneficence: if researchers are obligated to prevent harm, they must make reasonable efforts to detect clinically significant findings during their work⁵.
Similarly, there is considerable debate surrounding the duty to disclose incidental findings. Disclosure can lead to life-saving interventions, such as the early identification of malignancies, that would otherwise remain undetected. However, revealing findings of uncertain clinical significance—such as indeterminate lung or liver lesions—may cause unnecessary distress¹. This concern is heightened when findings cannot be readily treated or when patients may face significant barriers to accessing follow-up care⁶. The prevailing view in the literature holds that researchers do have an obligation to disclose incidental findings, but they must also ensure appropriate systems are in place to provide follow-up care or referrals to qualified physicians².
In conclusion, the ethics of detecting and disclosing incidental findings in radiology research remains complex and contested. For medical students and physicians, developing the skills to navigate these ethical challenges is essential preparation for both research and clinical practice. Early training in the thoughtful management of incidental findings fosters patient-centered care, promotes beneficence, and reinforces the importance of clear communication in the face of medical uncertainty.
References:
1. Ells C, Thombs BD. The ethics of how to manage incidental findings. CMAJ. 2014 Jun 10;186(9):655-6. doi: 10.1503/cmaj.140136. Epub 2014 Mar 31. PMID: 24688013; PMCID: PMC4049983.
2. Wardlaw JM, Davies H, Booth TC, Laurie G, Compston A, Freeman C, Leach MO, Waldman AD, Lomas DJ, Kessler K, Crabbe F, Jackson A. Acting on incidental findings in research imaging. BMJ. 2015 Nov 10;351:h5190. doi: 10.1136/bmj.h5190. PMID: 26556813.
3. Presidential Commission for the Study of Bioethical Issues, Anticipate and Communicate: Ethical Management of Incidental and Secondary Findings in the Clinical, Research and Direct-to-Consumer Contexts (Washington, DC: Presidential Commission for the Study of Bioethical Issues, 2013), 91.
4. Richardson HS. Incidental findings and ancillary-care obligations. J Law Med Ethics. 2008 Summer;36(2):256-70, 211. doi: 10.1111/j.1748-720X.2008.00268.x. PMID: 18547193; PMCID: PMC2575243.
5. Koplin JJ, Turner MR, Savulescu J. The Duty to Look for Incidental Findings in Imaging Research. Ethics Hum Res. 2020 Mar;42(2):2-12. doi: 10.1002/eahr.500043. PMID: 32233114.
6. Wolf SM, Illes J. Far from Home: Managing Incidental Findings in Field Research with Portable MRI. J Law Med Ethics. 2024;52(4):805-815. doi: 10.1017/jme.2024.169. Epub 2025 Jan 31. PMID: 39885754; PMCID: PMC11798668.
Ethical Considerations in Pre-Symptomatic Genetic Testing: An Essential Conversation for Medical Students
Author: Joshua Josef, MS1
Pre-symptomatic genetic testing (PSGT) identifies individuals at increased risk of developing disease later in life. PSGT provides both clinical and personal utility for patients, informing risk-mitigating intervention and life/family planning, respectively. While PSGT can help lessen disease burden and improve health outcomes, it can also lead to harmful outcomes if core ethical principles such as autonomy, beneficence, non-maleficence, and justice are not considered.
A case relevant to the utility and ethical aspects surrounding these tests is that of a woman who took a direct-to-consumer (DTC) genetic test to assess cancer risk. The woman was told that she carried a pathogenic BRCA mutation that gave her an 84% risk for breast and ovarian cancers, so she decided to undergo a double mastectomy and removal of her ovaries and fallopian tubes. However, four years later, her variant was reclassified as non-pathogenic – but the surgeries were irreversible.
This case shows that variant interpretation remains an imperfect and evolving science, highlighting the importance of informed consent to promote patient autonomy and ensure patient understanding of the limitations of PSGT before testing. Informed consent can be achieved through pre- and post-test genetic counseling, which helps patients understand that PSGT does not determine absolute disease risk and that variant interpretation is always in flux. After undergoing genetic counseling, patients can discuss appropriate risk-mitigating interventions with a physician or other licensed healthcare provider, which promotes welfare and mitigates harm.
Discussion with healthcare providers is especially important for patients undergoing DTC genetic testing, such as the woman in the case above. DTC PSGT provides a more affordable option for patients who cannot afford traditional physician-based genetic services, which increases access to PSGT and promotes justice. However, DTC testing is less regulated than traditional services, decreasing the reliability of test results. Thus, to prevent patients from making decisions based on incomplete or inaccurate information, policy must be in place to require genetic counseling and discussion with healthcare providers before medical intervention.
Genetic testing is becoming increasingly common in medicine, and all medical students will encounter it at some point in their careers. While genetic testing can be helpful for patients both medically and personally, there can be negative effects if essential ethical principles are not upheld. Therefore, engaging in ethical discussions during training will equip medical students with the perspective necessary to ensure genetic testing is conducted responsibly to promote the best outcomes for all patients.
Pediatric Medical Autonomy and the Mature Minor: Rethinking the 18-Year Threshold
Author: Emily Desai, MS1 & Aidan Kunju, MS2
This discussion challenges the ethical and legal assumptions surrounding pediatric medical autonomy by arguing that minors under 18 should be allowed to refuse life-saving treatment based on decisional capacity, not chronological age. Although 18 is the legal threshold for independent medical decision-making in most U.S. states, this rule reflects administrative convenience rather than scientific evidence about cognitive or emotional maturity.
We demonstrate this through landmark cases: in In re E.G., a 17-year-old Jehovah’s Witness successfully refuses a blood transfusion after the court recognizes her maturity and understanding of the consequences. In contrast, in Cassandra C., a 17-year-old in Connecticut is forced to undergo chemotherapy, highlighting how rigid age-based standards can override a minor’s informed refusal. We further examine the case of Daniel Hauser, a 13-year-old whose refusal of Hodgkin lymphoma treatment is overridden due to limited understanding, and Abraham Cherrix, a 16-year-old who is allowed to pursue alternative therapies after demonstrating decisional capacity. These examples expose how inconsistently courts apply the principles of autonomy, beneficence, and justice, depending not on a bright-line age, but on individualized assessments of maturity, prognosis, and family context.
We extend the argument by addressing contemporary controversies: minors seeking gender-affirming care, adolescents refusing psychiatric hospitalization, and religious refusals of blood transfusions, all of which expose the ethical instability of using age alone as the gateway to autonomy. We show that the mature minor doctrine, recognized formally in only a few states, provides a necessary but underutilized legal framework for respecting adolescents’ rights. Structured capacity assessments and ethics consultations emerge as practical tools for reconciling respect for emerging autonomy with the duty to protect life.
Shared decision-making and relational autonomy models further strengthen our position by illustrating how adolescents, families, and providers can collaboratively navigate life-altering choices without defaulting to rigid paternalism. In clinical practice, a 16-year-old confronting terminal leukemia often demonstrates more meaningful decisional maturity than a legally “adult” but developmentally immature 19-year-old.
Shared decision-making and relational autonomy models further strengthen our position by illustrating how adolescents, families, and providers can collaboratively navigate life-altering choices without defaulting to rigid paternalism. In clinical practice, a 16-year-old confronting terminal leukemia often demonstrates more meaningful decisional maturity than a legally “adult” but developmentally immature 19-year-old.
We argue that grappling with these real-world dilemmas forces future physicians to confront the critical question: Should the mere chance of cure override an informed, rational refusal? By confronting these tensions head-on, we show that individualized assessments grounded in maturity, understanding, and respect for young patients offer a more just, ethically sound alternative to the arbitrary 18-year age cutoff.
References:
1. In re E.G., 133 III. 2d 98, 549 N.E.2d 322 (1989).
2. In re Cassandra C., 316 Conn. 476 (2015).
3. Court Order, In re Daniel Hauser (Minnesota District Court, 2009).
4. Virginia General Assembly. "Abraham's Law," Virginia Code § 54.1-2969 (2006).
5. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;96(5):981-982
6. Bellotti v. Baird, 443 U.S. 622 (1979).
7. Ross LF. Children, Families, and Health Care Decision-Making. Oxford: Clarendon Press; 1998.
8. Osuna J, Fuentes S, Martínez B, et al. Involvement and autonomy of minors in medical settings: perceptions of children undergoing surgery and parents. Children. 2023;10(2):284.
Disability, Identity, and Reproductive Autonomy: Ethical Reflections on In Vitro Fertilization and Preimplantation Genetic Diagnosis
Author: Zhuochen Yuan, MS1
Advances in reproductive technology have enabled prospective parents to intentionally select specific traits in their children through in vitro fertilization and preimplantation genetic diagnosis. While typically employed to avoid debilitating genetic conditions, these technologies are increasingly used by parents seeking children who share culturally valued aspects of their identity. For instance, Deaf parents may deliberately choose embryos carrying genetic markers for deafness, viewing this trait not as a disability but as central to their cultural identity.
Such deliberate selection raises profound ethical questions. Is it morally permissible to select for traits traditionally labeled as disabilities? Does this choice harm the child by restricting future abilities, or is it an expression of legitimate cultural identity and reproductive autonomy? Central to this ethical debate is the “non-identity problem,” which argues that selecting an embryo with genetic traits for deafness cannot harm that child, as choosing a different embryo would have created an entirely different individual. The child selected can either live as a deaf person or not exist at all—raising the question of whether existence with deafness can be considered a harm if the alternative is non-existence.
We must examine these questions through three models of disability. The medical model views deafness as impairments needing correction, the social model frames disability as arising primarily from societal barriers rather than inherent deficits, and the affirmative model emphasizes disability as an identity and source of pride. Each framework uniquely influences whether selecting for such conditions is considered harmful, neutral, or empowering. There exists a broader movement within the Deaf community that embraces deafness as a unique language and way of life, rather than a disability. If so, is it morally permissible to choose a child with the deaf trait?
Now let’s consider a situation where parents with dwarfism or short stature select embryos carrying genes for conditions like achondroplasia, a decision that introduces ethical complexity due to associated health risks, including spinal stenosis and respiratory complications. This additional dimension challenges the balance between preserving cultural identity and considering the child’s medical well-being. Does the presence of significant health risks shift ethical considerations, or does respect for cultural identity continue to justify such reproductive choices? As future physicians encountering these complex reproductive decisions, we must thoughtfully engage with diverse patient values and concepts of health, underscoring the importance of cultural sensitivity and ethical reflection as medicine navigates evolving reproductive technologies and understandings of disability.
Balancing Risk and Responsibility: The Ethical Implications of Defensive Medicine
Author: Vikasni Mohan, MS3
Surveys have found that 80-90% of physicians practice defensive medicine.1 In an era of defensive medicine and overuse of medical tests and imaging due to a multitude of reasons, healthcare providers have exposed patients to unnecessary medical interventions and the stress and fear that accompanies it. While medical students are taught to diagnose patients primarily with a history and physical exam and then consider diagnostic testing, physicians in practice often order multiple tests to rule out very unlikely differential diagnoses that do not add much value to patient care. While we should provide patients with the best care that we can and rule out potential diseases, this can oftentimes lead to over-testing that can cause unnecessary fear and harm in patients.2 In essence, practicing defensive medicine can impact the ethical principles of beneficence and nonmaleficence that physicians should aim to uphold when practicing medicine and caring for their patients.
This practice also leads to excessive healthcare costs and affects resources available for those who need them, sometimes emergently. For example, defensive medicine is estimated to cost about $210 billion annually in the US,3 and approximately half of the imaging, labwork, and diagnostics ordered were found to be unnecessary and did not change management.4 In a healthcare system already strained by limited resources and physician time, over-testing can lead to delays in patient care and a lack of equal and equitable resource distribution.
Thus, it is important to consider all the reasons why we order certain diagnosis for patients and the impacts this can have on patients and the healthcare system as a whole. While it is important to accurately diagnose and treat patients, healthcare providers should be cognizant of the delicate balance between over- and under-treatment and should follow guidelines and best practices to help guide them in making decisions. Physicians should learn to weigh the risks and benefits of their diagnostic workup to minimize unnecessary harm to patients while also prioritizing the best interests of their patients and providing them with high-quality care.
References:
1. Lorenc T, Khouja C, Harden M, Fulbright H, Thomas J. Defensive healthcare practice: systematic review of qualitative evidence. BMJ Open. 2024;14(7):e085673. Published 2024 Jul 18. doi:10.1136/bmjopen-2024-085673
2. Gupta P, Gupta M, Koul N. Overdiagnosis and overtreatment; how to deal with too much medicine. J Family Med Prim Care. 2020 Aug 25;9(8):3815-3819. doi: 10.4103/jfmpc.jfmpc_433_20. PMID: 33110773; PMCID: PMC7586591.
3. Chen J, Majercik S, Bledsoe J, et al. The prevalence and impact of defensive medicine in the radiographic workup of the trauma patient: a pilot study. Am J Surg. 2015;210(3):462-467. doi:10.1016/j.amjsurg.2015.03.016
4. Koch C, Roberts K, Petruccelli C, Morgan DJ. The Frequency of Unnecessary Testing in Hospitalized Patients. Am J Med. 2018;131(5):500-503. doi:10.1016/j.amjmed.2017.11.025
Voluntourism or Sustainable Impact? Rethinking the Ethics of Medical Mission Trips
Author: Jose F. Eduardo Jr., MS3
Medical mission trips have the potential to provide life-saving care, improve community health outcomes, and inspire long-term partnerships. However, they have also sparked ethical debate, particularly around concerns of "voluntourism," where short-term interventions risk doing more harm than good. As the founder of a nonprofit that organizes medical missions focused on women's health, I’ve seen firsthand the transformative potential these efforts can have—when done ethically and responsibly.
There is a clear distinction between performative volunteering and truly impactful medical mission work. Best practices are rooted in building strong ties to community collaboration, continuity of care, cultural humility, and sustainability. I firmly advocate for thoughtful engagement, where the goal is not only to provide care, but also to build capacity and support local systems by bridging gaps in healthcare.
Without proper context and guidance, global health experiences can unintentionally perpetuate harm, disrupt local care systems, or prioritize volunteer experience over patient outcomes. These are valid concerns raised by critics of short-term missions. That is why it is essential for students to engage with the ethical dimensions of these activities, ensuring that their work is grounded not only in altruistic motivation but also in thoughtful, systems-based planning. In our missions, we have implemented strategies to ensure our interventions are both ethical and sustainable. These include guaranteeing timely access to test results through partnerships with local pathology labs and ensuring continuity of care by referring patients to local primary care physicians and specialists. For patients diagnosed with advanced-stage cancers, we have developed a patient navigation system involving local social workers, nutritionists, and oncology referral networks to coordinate follow-up care, insurance applications, and treatment support.
As future leaders in global health, we must encourage medical trainees to go beyond good intentions and instead commit to meaningful, collaborative service. Drawing from both personal experience and established ethical frameworks, I argue in favor of medical missions as powerful tools for sustainable change. Our work relies on collaboration with trusted community institutions, such as a church-run clinic that hosts our screenings, and on building relationships with medical equipment suppliers, laboratories, and care providers who remain long after our teams depart. When approached with this level of preparation and humility, medical missions can evolve into enduring alliances that foster the development of leaders who see service as a lifelong commitment to justice, equity, and responsible care—aligned with the principles of global health equity.
Informed Consent in Cataract Surgery: How Much is Enough?
Author: Constance Chen, MS3
How informed should a patient be when making an informed decision in selecting an intraocular lens (IOL) for cataract surgery in ophthalmology? As cataract surgery evolves with increasingly sophisticated intraocular lens technologies, patients face a growing array of options (monofocal, multifocal, toric, and light-adjustable lenses) that can lead to decision paralysis. This complexity not only challenges patient understanding but also imposes a significant educational burden on physicians, who may spend more time counseling than performing the surgery itself. Today’s physicians are advised to operate at “top of license,” with an emphasis on patient volume and quick turnarounds. Given the high clinical volumes, physicians are at risk for decision fatigue at the end of the day, which makes them more likely to compensate with cognitive shortcuts, such as presenting a limited subset of IOL options or rushing through informed consent. How then, do we balance both ethical and practical concerns?
The ethical dilemma centers on the balance between respecting patient autonomy through full disclosure and managing physician workload and well-being. Currently, there are several approaches being practice in clinic, yet no technique has been standardized. One option is providing informational IOL brochures which provide a comprehensive overview of the lenses. However, the differences might be too niche for patients to understand, and they may leave with more questions than answers. Another is providing a pre-recorded video by the physician for patients to watch prior to consultation that explains each of the intraocular lens type. But more often than not, the patient has not viewed the videos prior to their appointment.
Ultimately, there is no singular solution to reconciling these competing interests. Arguments can be made to support the patient for full procedure disclosure, but also for the physician to minimize decision-making options. This scenario challenges the ethical implications of various approaches to IOL counseling and highlights the need for innovative strategies that support both informed consent and sustainable clinical practice.
