Veljko Dubljevic

In the article “Nudging and Informed Consent”, Cohen argues that the use of “nudging” by physicians in the clinical encounter may be ethically warranted because it results in an informed consent where obligations for beneficence and respect for autonomy are both met. However, the author's overenthusiastic support for nudging and his quick dismissal of shared decision-making leads him to assume that “soft” manipulation is un-problematic and that “wisdom” on the side of medical professionals will suffice to guard against abuse. Opposing this view, we propose that: 1) patient preferences and values should not be boiled down to rational or irrational decisions based on cognitive reasoning alone, 2) potential threats to the physician-patient must be mitigated and could be minimized by employing alternative strategies that acknowledge the impact of cognitive heuristics in shaping decision-making but maintain transparency and trust, and 3) patient preferences and values can be legitimately influenced only under specific circumstances. The latter include: (1) exhaustion of other means; (2) evidence that nudging is effective in a specific context; (3) evidence of clear and active public misinformation (e.g., industry promoting smoking); (4) explicit pubic dialogue between various stakeholders including medical professional societies about nudging; (5) upholding shared decision-making as a preferred approach; and (6) a rich understanding of clinical reality beyond the simple dichotomy of beneficence-autonomy.

There is mounting evidence that non-invasive brain stimulation devices - transcranial direct current stimulation and transcranial magnetic stimulation could be used for cognitive enhancement. However, the regulatory environment surrounding such uses of stimulation devices is less clear than for stimulant drugs—a fact that has already been commercially exploited by several companies. In this paper, the mechanism of action, uses and adverse effects of non-invasive neurostimulation devices are reviewed, along with social and ethical challenges pertaining to their use as cognitive enhancements. Two regulatory approaches that could be used to facilitate responsible use of these devices as products and services are outlined. Apart from establishing the urgently needed comprehensive regulatory framework, they might provide a starting point for establishing long term physiological and social effects of enhancement uses of tDCS and TMS