At a time when more than one-third of American children are obese and type II diabetes is rampant, it’s hard to imagine why children’s hospitals — especially some of the very best — would put a McDonald’s front and center. But there’s a McDonald’s at the Children’s Hospital of Philadelphia, which U.S. News recently ranked alongside Children’s Hospital Boston as the No. 1 kids’ center in the country. In an online review of the Children’s Hospital of Los Angeles (ranked eighth by U.S. News), one parent observed that “McDonald’s is the only 24-hour food source. (Odd, since their food puts people in the hospital.)”  When “Super Size Me” director Morgan Spurlock learned about the McDonald’s at the highly regarded Texas Children’s Center (ranked fourth by U.S. News), he called it “utterly irresponsible” and “a flagrant violation of the doctor’s pledge of “Primum non nocere” (First, do no harm.)

Common sense makes it hard to argue with Spurlock, even though some equate those who share his view to “food police” preaching political correctness over personal choice. Yet to me, morality isn’t the issue. The question is why do children’s hospitals peddle McDonald’s and other fast food, even when they know they’ll get a black eye for doing it?

It’s not a question many of these hospitals want to answer. All of the hospitals I contacted with a McDonald’s on campus (Texas Children’s, Children’s Philadelphia, Children’s Los Angeles and several others), either declined to comment or didn’t return my calls. Even on their Web sites, the hospitals choose their words carefully. “It’s important for children to have good nutrition and their favorite food, especially when they are sick and in the hospital,” is how Rady Children’s puts it. Texas Children’s offers some pithy advice on how to order when you get in line at their McDonald’s — avoid the fries and don’t super-size.

The silence — and advice like that — speaks volumes about just how uneasy these hospitals are about selling Big Macs and fries to kids with diabetes and other chronic illnesses. On the other hand, McDonald’s Corp. was willing to explore these issues. Its answers, and a little history, sheds some light on what’s behind the relationship between Ronald McDonald and children’s hospitals.

“Like any business, when the restaurant is in or on the hospital campus, we lease the space and pay rent,” said Dr. Cindy Goody, McDonald’s senior director of nutrition. Follow the money — the marriage between fast food and children’s hospitals is, at its root, a side effect of competitive market forces in healthcare. Extra money is something that’s always necessary in pediatric healthcare, as volumes of kids need more attention, even as the money paid by insurers and the government declines. Hospitals need to make up the difference. As one researcher put it: “The incorporation of McDonald’s into a hospital environment must be seen … as a compromise between health and economic goals, a compromise that may have been avoided in other financial climates.”

Past reporting on this subject indicates that it’s often the hospital that first approaches the restaurant chain, seeking to replace a revenue-losing establishment with one that makes money. The outpatient cafeteria in St. Joseph’s Hospital and Medical Center in Phoenix, for example, was losing $19,000 a year before 1985. McDonald’s agreed to renovate the cafeteria, pay a flat fee for the lease and turn over a percentage of the profits. When a McDonald’s opened at Starship Children’s hospital in New Zealand in 1997, the hospital was guaranteed either an annual base return or a generous percentage from sales (from 7.5 percent of sales up to $1.29 million to 8.5 percent of sales above $1.69 million).

Once they’re in, McDonald’s and other fast-food outlets can be difficult to get rid of. Several years ago, the Cleveland Clinic, one of the nation’s most respected centers, made the decision to remove McDonald’s from its premises. McDonald’s fought back, refusing to terminate its lease early. It remains open today. In Canada, there have been similar efforts to close fast-food restaurants in other hospitals. Toronto Sick Children’s Hospital recently shuttered its Burger King franchise, though it took some public shaming for that to happen — a physician started a Facebook page demanding that the hospital make a change. “I’ve seen doctors remove their name tags when they’re in line, ordering super-value meals,” said Dr. Vishal Avinashi, who led the effort. “There’s obviously some guilt associated with that.” Nevertheless, the closure comes at a price. Over the years, Burger King raised more over $2.5 million for the hospital’s foundation.

For McDonald’s, the constant traffic through a hospital is a consistent source of profits. There are also some unexpected benefits for the company as well. Since McDonald’s is the archetypal bad guy in the war against childhood obesity, a hospital location vastly enhances the image of the company and its food. A 2006 study that looked at customers’ impressions of McDonald’s found clear evidence that parents who bought fast food at the hospital-based restaurants believed that McDonald’s Corp. was a hospital benefactor. More remarkably, they had positive perceptions of the healthiness of McDonald’s food. The researchers couldn’t explain why, but the company agrees. “Our menu fits into a healthy, balanced and active lifestyle. Children’s well-being requires an ongoing effort and we’re committed to being part of the solution to childhood obesity,” said Dr. Goody. Children’s Hospital of Philadelphia has even taken diabetic patients on field trips to its McDonald’s to learn how to stay on a diet.

Over the years, McDonald’s has found various ways to answer questions about its presence in hospitals and assuage its critics. At first, the company relied on cold pragmatism. ‘We go where there are people who need to eat, and there are a lot of people in hospitals,” said Ann Connolly, a former spokesperson for the McDonald’s Corp. back in the 1980s. More recently, the company has been pointing out it recent efforts to offer healthier menu options.

But it’s not evident that kids and their parents care to choose those healthier choices. That study by Dr. Boutelle showed that even when apple dippers and milk jugs were on the menu at Rady Children’s, families rarely ordered them. Apple dippers were purchased by anywhere from 0.3 percent to 3.6 percent of kids; milk from 1.1 percent to 6.6 percent of the time, depending on the age of the child. Almost no children purchased a yogurt parfait, apple juice or orange juice. On the other hand, french fries, soda, cheeseburgers, apple pie and the Big Mac were the most often-ordered items.

McDonald’s has its defenders. Put yourself in the shoes of a parent of a child with severe congenital heart disease, or a child with cancer on chemotherapy. Imagine having to come to the hospital over and over again for invasive and painful treatments. McDonald’s represents normalcy for many kids and their families, and could be a fun, comfortable place to go under very grave circumstances. It’s also worth noting that McDonald’s Corp. is the main backer of Ronald McDonald House Charities, which has built houses for families of hospitalized children to stay at, and over the years has donated hundreds of millions of dollars to help kids with cancer and other chronic illnesses.

As Spurlock writes: “The doctors at Texas Children’s Hospital told me they had young patients who were dying of cancer, and it was hard to get them to eat anything. At least these poor kids would eat some fries, take a bite of a burger: food they were familiar with. It was junk that they had been eating all their lives.”

That sums up a difficult alliance. I wonder, for example, if some of these children’s hospitals would even exist if not for their relationships with corporations like McDonald’s and others paying rent and sharing profits. It’s impossible to know what might not have been, but nobody wants kids losing access to something as fundamental as healthcare. So we close our eyes, sign the contract, hand Ronald McDonald our soul, and let our patients eat their french fries with packets of fancy ketchup.

A judge ultimately dismissed the case, stating that “the court does not find defamatory meaning, but rather a sometimes emotional discussion of the issues.” But it’s not the first time a physician filed a suit against a consumer for a bad Internet review — and probably won’t be the last. A physician’s reputation is all he or she has, and a sour review on the Web can make us very anxious.

Online review sites, of course, are imperfect and open to manipulation. But we all head to Google nevertheless in search of information and advice, whether we’re shopping for a book or a new physician. So how do you know whether the doctor you’re seeing is any good? And how do I know how good a doctor I am?

I recently Googled myself to determine how I fared on sites like Healthgrades, which exclusively rates doctors; and Yelp! and Angie’s List, which grade doctors alongside restaurants and plumbers. The results were inconclusive. Many sites had me listed but not rated. However, on Vitals.com I earned a mere one-star review (out of four). I had no idea who had rated me, or why I earned such a subpar grade. Some of the other information on the site was correct and some was not. It claimed I work at two four-star hospitals (that’s incorrect — just one four-star center), attended a three-star medical school, and that patients wait an average of 20 minutes to see me. It’s unclear how that number was calculated.

All of which suggests the amount of information online about doctors and the growth of ratings sites doesn’t make it any easier to figure out whether your doctor is brilliant or a quack.

The main reason for this is because it’s hard to figure out what “good” means. On one hand, it could mean delivering safe and effective care. Let’s call this high-quality care (though even defining “quality” this way is also sure to raise debate). Practically speaking, this could mean that if you bring your child to me with fever and an earache, I have the skill to diagnose an ear infection (an accurate exam) and prescribe the correct treatment (the right dose of the right antibiotic for the right number of days). On the other hand, “good” can also mean determining the kind of service I provided. When you brought your child to see me, did I greet you with a smile, listen, show some empathy? Was my office staff courteous and professional? Was it hard to find parking? Did you wait too long? Ideally, we want our doctors to give us both the highest-quality care and service. In reality, that’s almost impossible to judge.

Vitals and other sites have collected lots of anecdotal information about service — indeed, it’s one reason why the site was launched. “I was about to get my Achilles’ tendon repaired. On the table, the doc said, ‘I’m excited to do one of these. It doesn’t happen to me that often.’ That’s not the info I wanted to know then,” said Mitch Rothschild, the CEO of Vitals. “So we started Vitals to help people get that info ahead of time — when they are deciding, not when they are in a hospital gown.”

Rothschild said that we “are a social species — we care what other people think. And many of us make decisions not empirically, but by soliciting other people’s opinions.” Online sites are often the easiest place to speak out as well. After all, how many of us know where and how to file a formal complaint against a doctor or hospital?

But even with the best intentions and rationale, ratings sites have taken fire from the medical community. Much of this has to do with the traditional culture of medicine — new-media transparency causes a clash between the conservative and hierarchical nature of medicine and the forces that are trying to level the playing field between doctor and patient. In our guts, doctors are deeply uneasy about transparency; no one wants their strengths and weakness splayed for all to see in even the smallest open square, let alone anyone who Googles us. We want to care for patients in the best ways possible, despite all of the modern factors (insurance, bureaucracy, cost, risk) that have made this harder than in the past. So a negative review, while usually not leading to a lawsuit, often leads to anxiety, a crisis of confidence and concern for our reputation.

Doctors, of course, aren’t the only people who have to deal with potentially unfair reviews online. And most of us recognize that some criticism online is part of the deal these days. Nevertheless, doctors grounded in science bristle at the unscientific methods behind these ratings — especially if people are using them to make life or death decisions about medical care.

These sites also do very little to help me get better as a doctor or improve the doctor-patient relationship. Did my one-star review come from someone who felt I was rude or from someone who demanded a prescription but didn’t get one from me? With anonymity, it is impossible to tell. And even if I wanted to respond, federal privacy laws would not allow it.

That anonymity can also deceive our potential patients. A study looking at physician rating sites published in the Journal of General Internal Medicine last year identified several reviews that were written by doctors themselves. “Every anonymous review I’ve written on myself has been glowing,” confessed one doctor to researchers. On Vitals, I gamed the system myself. My own review went up from 1 to 3.5 stars after I entered several positive reviews. When I told Mitch Rothschild about this, he said, “We strive for the highest ‘signal to noise ratio’ by limiting the IP address’ ability to submit multiple ratings, asking for email afterwards, and then seeing if a doctor has many reviews with no emails — a suspicious note.” That didn’t stop me from entering those raves from my mobile phone, laptop, iPad and then my desktop.

Another problem academic reviewers of these websites have pointed out is that they often ask the same questions about a doctor regardless of her specialty. Asking whether a pathologist (who examines slides, not patients) communicates a diagnosis to a patient well doesn’t make sense at all.

Perhaps the biggest limitation with Vitals and other sites has to do with the paucity of reviews. While Vitals claims it has information on some 720,000 doctors, according to Rothschild, each doctor has only an average of four ratings. In another study of physician rating sites, researchers found that only three out of 250 doctors had been rated five or more times. Given the thousands of patient visits one doctor will take part in each year, one-to-four opinions hardly counts as the wisdom of the crowd.

Despite all of these criticisms, it’s worth noting that nearly 90 percent of reviews, as sparse as they are per doctor, are positive, suggesting that doctors’ collective angst is probably overblown. Still, in an effort to fight back, some doctors have taken to making their patients sign gag orders that prevent them from writing reviews online. Others have “incentivized” patients to favorably review them online by offering discounts on certain services. (Botox for four stars, anyone?) Some have suggested perhaps the best thing to do is to actually encourage patients to use these sites so the overall number of good reviews drowns out bad ones.

So if service “data” is not necessarily helpful for figuring out how good a doctor is, what about quality statistics? Some states have taken to publishing hard outcome data about certain doctors. New York, for example, publishes data on the performance of its cardiologists and cardiac surgeons. It’s an impressive set of spreadsheets dating back to the 1990s. But this kind of data does not exist for all doctors, and for the ones it does exist for, it certainly isn’t easy to find. Even if they did find it, it’s pretty clear from studies and surveys that consumers aren’t motivated to drill this deep into statistics to figure out which doctor is right for them. From a physician’s standpoint, there is some indication that cardiologists and CT surgeons may be reluctant to treat riskier patients for fear of getting dinged on these spreadsheets. Finally, to get back to the root of my inquiry: Can data like this help doctors get better? No study has suggested any proof that it helps.

The result of all this push toward transparency doesn’t seem to have affected consumers. A 2008 survey by the California HealthCare Foundation found that although more than 80 percent of the state’s adults turn to the Internet for health-related information, less than one-quarter have looked at physician ratings sites. Only 2 percent of those surveyed made a change in physicians based on information posted on a rating site. Other surveys demonstrate similar lack of influence for published quality data.

All this puts us back at square one when it comes to figuring out how good our doctors are. Service and quality are both essential skills for doctors to master, but online rating sites don’t have enough information to attest to quality. And the states’ quality data tells us nothing about bedside manner.

Perhaps “how good is your doctor?” is the wrong question to ask. Given how complex medicine and medical care is these days, no single doctor can know it all and do it all. Instead, it may be better to look for a system of care — primary care, specialists and other members of a team — that works to provide quality care and multi-star service in a coordinated fashion. A few such systems exist around the country, and as healthcare reform continues, we’ll probably see more sprouting up. If you’re skeptical of that view, just look at the scandal in the military at Walter Reed Hospital. That shameful service and quality wasn’t because of a single doctor, but because the entire system meant to take care of wounded soldiers was in shambles, leaving patients out in the cold. 

But, as a doctor, I was struck by a more subtle medical conundrum. Toward the beginning of the movie, scientist Will Rodman (James Franco) injects his Alzheimer’s-stricken father (John Lithgow) with the same drug he gave Caesar. In the following scene, Lithgow’s character recovers the memories and mental capacity he lost to dementia. That particular plot point raises a question we as physicians often face: Should doctors treat their own family and friends?

The practice is officially frowned upon. Most medical associations and many state boards consider caring for relatives or friends to be a form of professional misconduct. Insurers don’t support the practice either: To curb fraud, Medicare stopped reimbursing doctors for treating family members nearly two decades ago, and Blue Cross hasn’t paid doctors for taking care of relatives since 1976. And legal issues abound: Physicians can be liable for off-the-cuff diagnoses made at the bequest of family or friends. In 1990, a Chicago doctor was tried for murder after his wife died from complications from liposuction.

But these guidelines and legal ramifications do little to deter us from becoming, literally, the doctor in the house. In 1991, the New England Journal of Medicine published one of the few studies of this practice. It found that 99 percent of surveyed physicians admitted to providing medical care for a family member. Eighty-three percent of physicians had prescribed medication, 80 percent had diagnosed medical illnesses, 72 percent had performed physical examinations and 15 percent had acted as a family member’s primary doctor. And we’re not just talking about treatment of minor scrapes and sniffles: 9 percent of doctors in the study had actually performed surgery on a family member. Others had diagnosed cancer, strokes and other serious illnesses for their relatives. This physician tendency to care aggressively for relatives is echoed by Will Rodman’s behavior in the latest “Apes” film: The drug he gives his father is experimental and hasn’t been approved for human trials.

Dispensing advice to friends and family begins as early as medical school, but the breadth and depth of our involvement grows rapidly. In my own career I’ve given my wife flu vaccines, prescribed steroid ointments for my father, and birth control pills for my cousin. I diagnosed a subtle wrist fracture in my neighbor’s kid and signed a health form over my backyard fence to give another neighbor’s son permission to play basketball (I asked the parents to let me review his chart before I put pen to paper).

It’s hard to turn down a friend or relative asking for basic medical advice, and many physicians (myself included) enjoy this sense of giving something back to our families and communities. But issues arise when we treat people with whom we have personal relationships. For one thing, many such requests often deal with issues outside our area of expertise. As a pediatrician, I don’t always feel qualified to answer questions about adult medical matters.

Even more problematic is our loss of objectivity. Given the added emotional anxiety of caring for a family member, the first diagnosis that pops into my mind when I’m treating a relative is often the worst. Case in point: At 9 months old, my oldest daughter began intermittently vomiting for a few days. Her pediatrician would likely have examined her and told us she had a case of the stomach flu. I, on the other hand, convinced myself she had developed type 1 diabetes or a urinary tract infection. A day or so later, our daughter was back to her usual rambunctious self, but not before I’d ordered costly blood work, and attempted to collect a urine sample using a plastic bag (which you stick to a child’s genitalia) rather than a catheter (which is standard practice for infants). No studies have compared the cost and quality of healthcare doctors give to their patients versus their loved ones and neighbors. But if my experience is any guide, we’re likely to give our loved ones costlier but shabbier care.

These sorts of personal consultations can complicate care for patients as well. Once, the parents of a 7-year-old patient of mine came to see me. Their daughter had developed a fairly serious condition, and they’d been consulting a family friend who was an adult specialist over the phone. True to form, he had suggested a whole battery of tests, including an ultrasound. Based on the child’s story, the diagnosis was pretty clear, and it only required a urine sample and a few blood tests, certainly not a high tech, expensive scan. The parents later told me that their doctor friend had ordered the ultrasound himself. I didn’t want to put the child in the middle of a medical turf war, so I didn’t try to talk them out of it. What bothered me most was that the physician who ordered the test didn’t bother to tell me what the results were (I dug them up on my own). And it easily could have put our patient at risk, had the other physician prescribed medication without my knowledge or needlessly subjected her to radiation from a CT scan.

There are exceptions, like actual emergencies, but as a rule we doctors need to get better at saying no when it comes to treating our friends and loved ones. And it can certainly help to be a medical expert when you’re translating medical information and advocating for a loved one or friend. But boundaries are important. The aggressive urge to ensure that our loved ones are getting the very best, most medically advanced care often ends up doing more harm than good: In “The Rise of the Planet of the Apes,” Will’s father eventually begins to experience unexpected side effects from his son’s miracle drug, and his Alzheimer’s returns.

Now, when I get casual questions from friends and family, I try to stick to general advice and then recommend they visit their own doctor. In our prescription and test-driven healthcare system, the last thing we need is to be encouraging costlier, less effective care.

Real hypochondria, which today we believe is a form of extreme anxiety connected to depression and obsessive-compulsive disorder, is serious, costly and debilitating. A brief perusal of hypochondria message boards will show you how terrifying the disorder really is. Driven by the frightening and unwavering conviction that every twinge, tingle and ache is a mortal threat, these patients can’t stop calling 911, making doctor’s appointments and demanding test upon test, drug upon drug. It adds up: Collectively, hypochondriacs cost our health system some $20 billion a year.

Modern culture provides fertile ground for this sort of anxiety. Google any ache or pain you might have, and you’ll find a long list of life-threatening diagnoses. The term “cyberchondria” has been coined to describe those who spend too much time “e-searching” ailments. A Microsoft study revealed that half of the company’s employees interrupted their day at some point to search for medical information online. More troublingly, researchers found that these searches often popped up the worst possible diagnoses. There’s even an iPhone app that caters directly to the hypochondriac.

The 24-hour cycle of health news and entertainment that gives superficial information about every drug, diagnosis and disease gives hypochondriacs even more fodder. One message board commenter, for example, wrote after actress Brittany Murphy’s death, which was initially believed to be caused by a heart attack, in 2009: “I have been to the cardiologist and the ER I don’t know how many times complaining about my chest pains and I get the ‘you’re too young’ speech but they still perform the test anyway! Too young for a heart attack! Huh! Tell that to Brittany Murphy. I am 31, she was 32. I’m freaking out!”

As upset as this writer is with her cardiologist’s attitude, I can assure you her physicians were equally frustrated. Interacting with a hypochondriac patient puts an immense strain on the doctor-patient relationship. Hypochondriacs are desperate for us to believe that the symptoms they’re experiencing are physically real, not psychologically motivated; they come to our offices desperate for validation, support and certainty. When we cannot give them any of those things, they refuse to believe our assessments and both parties drift farther apart in anger.

One patient rails on an online message board: “The deeper we dive the more we discover about how little [doctors] actually know about medicine. They have no understanding of risk factors, or root causes, or genetics … The damn doctors are fools. All of them … ” The medical community’s response is equally hostile. We routinely avoid, and even fire, hypochondriac patients from our practices. We label them with derogatory names, like “crazy,” “gourd” or the more modern acronym “GOMER” (get out of my emergency room). But in the end, after hours and hours of visits and phone calls, we often find ourselves pressured into ordering tests, writing prescriptions and making referrals just the same.

Today’s medical system encourages this approach of hurrying difficult patients out the door. Doctors, unlike lawyers or consultants, don’t bill for their hours. Most of us get reimbursed by insurance companies for tests, and procedures, and prescriptions, often regardless of whether they’re necessary. A hypochondriac on our schedule is a time and money sink. The ugly truth is that modern medicine doesn’t reward those physicians — like primary care doctors — whose main work is to listen to and think deeply about patients and their ailments, whether they are physical or psychological.

As a pediatrician, I’ve had a single brush with hypochondria by proxy. My patient was a teenager with multiple minor complaints — a little fatigue, a string of recent colds, some oral cold sores. Her mother pushed a piece of paper at me, and asked me to order a specialized test for Lyme disease, one I had never heard of. The mother, after doing Internet research and discussing the illness on message boards, was convinced that this was her daughter’s diagnosis, even though her symptoms didn’t suggest it. I tried over and over to reassure her, but she only waved more and more printouts at me with information to support her diagnosis.

It’s this lack of faith between the hypochondriac and his or her doctor that’s at the core of each party’s frustration. The mother refused to believe me. For doctors, this reaction violates the deep desire we have for patients to trust us. It also erodes our confidence. As Susan Baur notes in her book on the subject: Hypochondriacs’ “consistent failure to improve makes it difficult for the doctor to feel effective, just as their lack of consideration and appreciation makes it hard for him to like them and thus feel kind and friendly. Few doctors can tolerate being cast in the dual role of nasty person and impotent healer.”

With the parent of my patient, I held my ground for over an hour. In the end we negotiated that I would dig into her ream of printouts later and then call her to discuss it further. It didn’t take long to learn that the custom test the mother had championed lowers the bar for what constitutes a diagnosis of Lyme disease, so that essentially everybody who takes it receives that diagnosis. When I expressed my concerns to her, she insisted, “There’s no such thing as a false positive Lyme test.” Before I could respond, she got angry and accused me of obstructing her child’s path to health. Needless to say, like countless other doctors and hypochondriacs, we parted ways.

Knowing what I know now about the nature of hypochondria, all of this was easy to foresee. The mother of this child wanted, desperately, to get her daughter a diagnosis, a grand unifying explanation for what was likely nothing more than a bunch of random ailments strung together. Had I ordered that lab test and given her this false diagnosis of Lyme disease, I would have sentenced her to 6 months of intravenous antibiotics through a surgically placed central line.

What should I have done differently? Experts (of which there are very few) in the study of hypochondria suggest the exact opposite of avoidance:

Successful long-term medical management requires a durable and trusting doctor-patient relationship … Visits should therefore be scheduled on a regular, rather than an as-needed, basis … A few patients may still make excessive requests for attention, in which case the physician must set limits in a non-punitive manner … tests and specialty consultations should not be performed solely for the purpose of reassurance … [this] must be coupled with the explicit assurance that the physician understands that such symptoms are real and not “imaginary.”

Good advice, but in the time-sensitive setting of the office, with a desperate and hostile parent in your face, that’s easier said than done. Unless we restructure the way our medical system works, we’ll continue doing a disservice to those terrified patients who arrive at our offices convinced — by Google, or Dr. House or the nightly news — that they already know their life-threatening diagnosis.

“Enhanced Eddie” then acquires a stash of these pills and, in rapid succession, cleans himself up, learns Italian, wins back his ex-girlfriend and becomes a celebrity investment banker.

The film’s “miracle” drug may seem far-fetched, but it’s based in a medical reality: Taking certain medications, specifically those developed to treat psychiatric and neurological disorders, can boost cognitive performance in otherwise healthy people.

Many of us instinctively recoil from such an idea for moral reasons. Sculpting our brains, unlike, say, sculpting our noses, seems like cheating. But consider this: 7 percent of surveyed college students (and some 25 percent of those on elite campuses) have taken an unprescribed Ritalin — or a similar drug used to treat attention deficit disorder — to boost their performance on an exam.

And the phenomenon is not restricted to college students trying to raise their grade point averages: The military has a history of encouraging — and sometimes even ordering — soldiers to take Ritalin or Provigil, a drug that boosts alertness. Canadian researchers are now looking at a drug called metyrapone that may help dull the sting of painful memories. Already common is the number of executives who swallow a little dose of Propranolol — which is normally used to treat high blood pressure but has also been prescribed for performance anxiety for many years — to calm their nerves before they speak. And with so many of us already hustling to Starbucks morning, noon and night for shots of caffeine to keep us going, the question arises: Is there a case to be made for cognitive enhancement?

A few years ago, a distinguished group of scholars claimed there was in an essay in Nature:

Human ingenuity has given us means of enhancing our brains through inventions such as written language, printing and the Internet … And we are all aware of the abilities to enhance our brains with adequate exercise, nutrition and sleep … drugs … should be viewed in the same general category as education, good health habits, and information technology — ways that our uniquely innovative species tries to improve itself.

The writers proposed a series of principles that would help society regulate these drugs responsibly and fairly. These rules stipulated that any mentally competent adult would be allowed to use cognitive enhancing drugs, that professional organizations would develop policies for their prescription and use, that detailed research would be conducted regarding their risks and benefits, and that access to such medications would be provided regardless of socioeconomic status.  

The authors correctly point out that “there is certainly a precedent for this broader view in certain branches of medicine.” Lifestyle drugs like Viagra are an over $30 billion a year business. And then there are substances like caffeine and alcohol that we commonly use as lifestyle drugs — to keep us up, to help us relax, to make us focus, to put us to sleep — even if we don’t think of them that way. There are also those of us — myself included — who take drugs we wouldn’t normally think of as lifestyle drugs and use them as such.  If I’m going to drink a few glasses of wine over dinner, or have an extra cup of coffee to get through my day,  I’ll sometimes pop a Prilosec so that I don’t wake up in the middle of the night with heartburn.

But taking a pill to get an edge for that job interview or ace that test is deeply unsettling. On a visceral level, the idea that we’re “playing God” with our minds disturbs us. There’s also the question of what happens to our sense of accomplishment. What does it mean if achieving your dreams merely means popping a pill?

There are two more concrete arguments as well. First, access to these mind-altering substances would likely (at least initially) be limited to those with the money to afford them. The authors of the essay in Nature try to allay this fear by suggesting, somewhat naively, that every exam-taker have free access to cognitive enhancements “as some schools provide computers during exam week to all students.” But it’s easier to imagine the society predicted by the President’s Council of Bioethics in 2003, where we see “the emergence of a biotechnologically improved aristocracy. [This] is indeed a worrisome possibility, and there is nothing in our current way of doing business that works against it. Indeed, unless something new intervenes, it would seem to be a natural outcome of mixing these elements of American society: our existing inequalities in wealth and status, the continued use of free markets to develop and obtain the new technologies, and our libertarian attitudes favoring unrestricted personal freedom for all choices in private life.”  

Finally, we can’t ignore any known and unknown risks of the side effects of cognitive enhancers. In “Limitless,” we see Eddie become increasingly dependent on his drug, which leads him to visual hallucinations and memory loss. With Ritalin, we worry about sleep disturbances, high blood pressure, weight loss and emotional instability. With Provigil, there are concerns of visual hallucinations, insomnia and depression.

Of course, it’s easy to make these judgments in the abstract. But what if, for example, your child needs a lifesaving but risky and complex 15-hour surgery? Wouldn’t you want that doctor to be as alert as possible throughout the procedure, even if that meant using Provigil or another cognitive-enhancer? Or what if your son is on the ground in Afghanistan? Wouldn’t you want him to be able to take a dose of Ritalin before going on patrol, so he’s sharp and ready to defend himself?  

But regardless of your personal feelings on that matter, our ability to innovate will continue to challenge our sense of morality. We can’t simply pretend that these drugs don’t exist. The writers in Nature deserve credit for being willing to start this conversation. Still, for all of their logic, their biggest fault is their dismissal of the role of human hubris and ambition. Perhaps Eddie Mora says it best: “There are no safeguards in human nature. We’re wired to overreach.”