Prescribing Stimulants in College Populations: Clinical and Ethical Challenges

Objective: Increased concern exists regarding non-prescription use of stimulants in college populations such as for perceived enhancement of cognition and subsequent improved academic performance or for recreational purposes. Psychiatrists face serious clinical challenges in making a new diagnosis of adult ADHD in college-age patients and distinguishing between students who have legitimate ADHD symptoms versus students seeking secondary gain. Methods: A hypothetical case will illustrate those challenges and an ethics-based framework named dialectical principlism will be applied to the case to demonstrate how the competing considerations can be balanced to inform a resolution for this clinical dilemma. Results: The weighted considerations related to principles of autonomy, beneficence, nonmaleficence, and distributive justice were balanced to favor not prescribing stimulant medication in this hypothetical situation. Others might come to the opposite conclusion using the same dialectical principlism model because their unique narrative and set of values may lead to weighing the importance of these principles differently and thus altering the balance in the other direction. Conclusion: The method of dialectical principlism was applied to this hypothetical to illustrate how practitioners can make clinical decisions guided by what is most ethical after identifying, prioritizing, and balancing the competing considerations. Dialectical principlism is primarily an aspirational model for practitioners, with the goal of empowering them with a systematic approach to determine the best way to resolve complex challenges via an ethics analysis.