The Stain of the Spotless Mind: Policy Recommendations for Memory Erasure

By Peter Leistikow

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris of Summer 2016.

Peter Leistikow is an undergraduate student at Emory University studying Neuroscience and Sociology. When he is not doing research in pharmacology, Peter works as a volunteer Advanced EMT in the student-run Emory Emergency Medical Service.

Over the course of 15 years, psychologist Dan McAdams studied how Americans describe their lives. Specifically, McAdams wanted to know what kind of life narratives were associated with lives high in “generativity;” that is, a concern for and commitment to promoting the well-being of future generations. He ultimately discovered that generative adults had narrative identities that emphasized redemption, such as a second chance or delivery from suffering (McAdams 2006).

The observation that it might be essential to have overcome adversity, reaping all the lessons and baggage it entails, in order to become a compassionate, mature adult is especially important in light of new developments in the field of dampening or even erasing memories. This alarming area of research warrants a further examination by policymakers, and it is the recommendation of this briefing that decisive limitations should be imposed on access to this technology.

Image courtesy of Flikr

Memories were not always considered malleable; it was not until the 1960s that experiments in rats challenged the ideas that memories could be subjected to further modification, given the right conditions (Singer 2009). Fearful memories are made when emotionally salient events are labeled by the amygdala in the brain as emotionally significant and sent to the hippocampus for consolidation, strengthening synaptic connections into what will become a memory (Lu 2015). However, these connections can be disrupted; current therapies for post-traumatic stress disorder (PTSD) aim to block reconsolidation after reactivating these traumatic fear-based memories or promote extinction learning, a re-conditioning of fearful stimuli (Guistino et al. 2015). These are precisely the pathways targeted by drugs such as propranolol, a repurposed beta blocker that has been given hyperbolic names such as “the magic pill” or “a drug to cure fear” for its ability to alter memory reconsolidation, even allowing people with arachnophobia to touch spiders during exposure therapy (Scutti 2013; Friedman 2016). On the non-pharmacological front, developments in areas such as optogenetics may allow for the precise targeting of light sensitive proteins of the brain’s fear circuitry; devices that electrically stimulate the brain, the veritable alphabet soup of TMS, DBS, and tDCS, may strength exposure based therapy (Milad et al. 2014).

Limitations of this technology exist; in studies of pharmacological interventions such as D-cycloserine (DCS), it was shown that DCS can actually augment traumatic memory reconsolidation if paired with unsuccessful exposure therapy (Hoffmann 2014). Propranolol too may have adverse effects, negatively impacting other forms of memory such as semantic memory (for facts) and procedural memory (for things like how to ride a bike) that are interconnected and located close to sites of fear memories (Aoki 2008). Nevertheless, memory altering technology is here, and advances in technology will only increase its prevalence.

Thus, memory dampening technology requires intense scrutiny, and its use should be curbed such that it is only supplied in a clinical setting for only the most severe cases of PTSD. Central to this assertion are issues of personal identity and authenticity, appropriate moral response and traumatic growth, and justice. Memory dampening technology could cause significant harm to each of these values should it be allowed to reach prevalence in general practice or for cosmetic use.

Image courtesy of Wikicommons

The 18th century Scottish philosopher David Hume defined the self as the connections within a discrete “bundle” of sensations and experiences; he believed that any changes in memory would be a change to the very self (Gentile 2010). Contrary to this view, some modern ethicists view memory erasure as a way to return to what is closer to the true self than the individual would have been living life dominated by the traumatic memory (Kolber 2011). Implicit in this assumption is that there is a self that is wholly independent from life circumstances; that character is static, and is not built by repeated actions and thoughts. Erler (2010) states that even core aspects of the “true self” such as personality and disposition can change over time despite being independent of choice; thus, it is inaccurate to appeal the true self as an abstract “essence.” Nevertheless, it is important to maintain authenticity by rejecting frivolous use of memory dampening technology. Erler (2010) states that it is inauthentic to change one’s memories such that “they change themselves in a way that distorts their perception of the world.” He goes on to offer the example of Liz, whose ability to unconditionally forgive the bullies of her adolescence following memory erasure would be contrary to the real harm she suffered that informed her reluctant nature, regardless of the nobility of the sentiment (Erler 2010). Indeed, emotions reveal deeply held concerns that are a product of one’s experiences and inform movement through moral space (Kabasenche 2007).

Memory also figures into broader aspects of appropriate moral response. Removing memory of an event deprives one of the experience of exercising agency in cognitively appraising the event and even possibly addressing larger social ills (Liao & Sandberg 2008). Furthermore, experiencing hardship allows one to become more empathetic to the struggles of others, a moral betterment. For example, Wallace (2011) explains how the experience of a nearly fatal car crash allowed him to not only gain the wisdom to critically evaluate his priorities, but also a deep compassion for others; the trauma is inseparable from the transformative experience it became. However, not all experiences are transformative for the individual. As Kolber (2006) states, some experiences of senseless violence seem to offer no opportunities for growth, and in some cases individuals are so impaired that they can no longer derive growth from hardship; these would be severe cases of PTSD in which it might seem permissible to use memory dampening drugs under rigorous clinical observation. Unfortunately, any criteria defining differentiating “severe” PTSD from “normal” PTSD would be largely arbitrary, and would be subject to cultural and economic pressures from outside the medical field. The use of memory dampening in cases of inconsistently defined cases of extreme PTSD sets the stage for further widespread medicalized treatment of trauma that “pathologizes” normal aspects of the human experience, leaving consumers ripe for exploitation by corporate pharmaceutical interests (Bell 2007).

Lastly, memories must be preserved in order to administer justice in accordance with the laws of society. For example, survivors of sexual assault may be further stigmatized and less likely to report the crime committed against them if standard treatment involves the use of memory erasing drugs that may call their testimony into question (Chandler et al. 2013). Although many sexual assault survivors report a high incidence of severe PTSD, Chandler et al. (2013) also state that memory deficits are associated with PTSD; in extreme cases the ultimate outcome is still one that favors justice, as memory erasure may enable testimony of equal or greater clarity. Ultimately, prohibition of prophylactic memory erasure while allowing erasure in cases of extreme suffering optimizes justice for society and survivors. This tension between societal and individual good is also seen in other cases, such as the maintenance of collective memory for tragedies, in which societal justice is served by limiting the individual’s access to memory erasure (Tenenbaum &Reese 2007). Clearly, policy changes in memory erasure technology will have to accompany a reevaluation of the individual’s duty to society cross culturally.

Thus, it is the recommendation of this briefing that memory erasure should be prohibited. Memory erasure technology has the potential to be a destructive force if allowed to reach prevalence among the general populace; the time is now to impose regulation that will preserve authenticity, personal identity, growth, and justice. Life narratives, always in flux, should embody the whole life experience without the tyranny of selective erasure.

References



Aoki, C.R.A. 2008. Rewriting my autobiography: The legal and ethical implications of memory-dampening agents. Bulletin of Science Technology & Society 28(4): 349-359. doi: 10.1177/0270467608320223



Bell, J.A. 2007. Preventing Post-Traumatic Stress disorder or pathologizing bad memories. American Journal of Bioethics 7(9): 29-30. doi:10.1080/15265160701518540



Chandler J.A., Mogyoros, A., Rubio, T.A., & Racine, E. 2013. Another look at the legal and ethical consequences of pharmacological memory dampening: The case of sexual assault. The Journal of Law, Medicine, and Ethics 41(4):859-71. doi: 10.1111/jlme.12096.



Erler, A. 2011.Does memory modification threaten our authenticity. Neuroethics 4:235–249.

doi:10.1007/s12152-010-9090-4



Friedman, R.A. 2016. A drug to cure fear. The New York Times, January 22. Available at: http://www.nytimes.com/2016/01/24/opinion/sunday/a-drug-to-cure-fear.html?_r=0 (accessed on June 19, 2016).



Gentile, S. 2010. If we erase our memories, do we erase ourselves. Public Broadcasting Service, November 24. Available at: http://www.pbs.org/wnet/need-to-know/the-daily-need/if-we-erase-our-memories-do-we-erase-ourselves/5322/ (accessed June 19, 2016).



Hoffmann, S.G. 2014. D-cycloserine for Treating Anxiety Disorders: Making Good Exposures Better and Bad Exposures Worse. Depression and Anxiety 31(3):175-177. doi:10.1002/da.22257



Giustino, T.F., Fitzgerald, P.J., & Maren, S. 2016. Revisiting propranolol and PTSD: Memory erasure or extinction enhancement. Neurobiology of Learning and Memory 130:26-33. doi:10.1016/j.nlm.2016.01.009



Kabasenche , W.P. 2007. Emotions, memory suppression, and identity. American Journal of Bioethics 7(9): 33-34. doi: 10.1080/15265160701518581



Kolber, A. 2006. Therapeutic forgetting: The legal and ethical implications of memory dampening. Vanderbilt Law Review 59:1561-1627.



Kolber, A. 2011. Give memory-altering drugs a chance. Nature 476: 275-276. doi:10.1038/476275a

Liao, S.M. & Sandberg, A. 2008. The normativity of memory modification. Neuroethics 1:85-99. doi: 10.1007/s12152-008-9009-5



Lu, S. 2015. Erasing bad memories. Monitor on Psychology 46(2):42.



McAdams, D. P. 2006. The redemptive self: Stories Americans live by. New York, NY: Oxford University Press.



Milad, M.R., Rosenbaum, B.L., & Simon, N.M. 2014. Neuroscience of fear extinction: Implications for assessment and treatment of fear-based and anxiety related disorders. Behavior Research and Therapy 62: 17-23. doi:10.1016/j.brat.2014.08.006



Scutti, S. Memory, forgetting and propranolol: Should some experiences never be recalled. Medical Daily, July 8. Available at: http://www.medicaldaily.com/memory-forgetting-and-propranolol-should-some-experiences-never-be-recalled-video-247469 (accessed on June 19, 2016).



Singer, E. 2009. Manipulating Memory. MIT Technology Review, April 21. Available at: https://www.technologyreview.com/s/413109/manipulating-memory/ (accessed on June 19, 2016).



Tenenbaum, E.M. & Reese, B. 2007. Memory-altering drugs: Shifting the paradigm of informed consent. The American Journal of Bioethics 7(9): 40-42. doi:10.1080/15265160701518649



Wallace, L. 2011. Even if we could erase bad memories, should we. The Atlantic, May 10. Available at: http://www.theatlantic.com/health/archive/2011/05/even-if-we-could-erase-bad-memories-should-we/238444/ (accessed on June 19, 2016).



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Leistikow, P. (2016). The Stain of the Spotless Mind: Policy Recommendations for Memory Erasure. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/09/the-stain-of-spotless-mind-policy.html

A Corner on the Neuromarket

By Sol Lee

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris of Summer 2016.

Sol Lee studies Neuroscience and Behavioral Biology at Emory University. As a pre-med student, he is enthusiastic about primary care and global health concerns. Sol is currently doing research on glutamate receptors in Parkinson’s Disease in the Smith Lab.

Ever since its inception in 2002 [1], neuromarketing has been a rapidly developing and highly controversial field. Neuromarketing employs neuroscience research in order to advertise products and services and is primarily utilized by companies to better understand the brain’s responses to marketing stimuli and advertising [2]. Methods include analysis of galvanic skin response, which can be used to measure stress, and eye tracking, which measures eye location and movement. Common medical research techniques such as functional magnetic resonance imaging (fMRI), which measures brain activity by detecting changes in cerebral blood flow, and electroencephalography (EEG), which measures electrical activity in the brain, are also utilized [3]. With these techniques, neuromarketing promises to create advertising methods that are more impactful and enticing. Although neuromarketing holds much potential in this regard, there are concerns about the ethical implications of this emerging field. Concerns about neuromarketing include the potential for deceptive consumer coercion, infringement of consumer privacy rights, complicating legal ramifications, and inappropriate weighting of private versus public interests. This paper will attempt to address concerns about neuromarketing and propose guidelines for a proper course of action.

Neuroscience technologies used in neuromarketing are relatively new [5]. As neuromarketing techniques advance and become more effective, there is a growing concern that consumers might be deceived into buying a product that they do not want or need. While this may seem no different than typical marketing strategies of the past, a new ethical concern arises with neuromarketing due to its potential to apprehend the research participant’s information beyond their conscious awareness and circumvent consumers’ rational thought processes. A study in 2004 [6] gained widespread attention when its results highlighted this possibility. In this study, fMRIs revealed higher levels of activation in brain regions associated with reward when participants drank Pepsi as opposed to Coke. However, when participants were told that they were drinking Coke, fMRIs revealed activation in brain regions associated with memory and emotional processing. This phenomenon was not observed when participants were told they were drinking Pepsi. This study provides evidence against the common belief that consumer preferences directly align with the physical properties of the product. Rather, past experiences and exposure to marketing might affect our preferences and decisions in a top-down manner.

Image courtesy Wikicommons.

The government grants freedoms such as free speech and free market, but even those freedoms must be monitored to ensure the rights of citizens. For instance, it is illegal for a person to shout “fire” in the middle of a crowd when there is no fire because that person’s right to free speech will interfere with other people’s rights to general public safety [7]. In a similar manner, within the existence of a ‘free’ market, in order to make informed, rational decisions, consumers have the right to be given adequate and accurate information when purchasing products or services. The FTC regulates laws that protect consumers on a national level, and many states have adopted legislation such as the Uniform Deceptive Trade Practices Act [8], which protects consumers’ rights to accurate product information.

Another ethical issue regards the privacy of consumers. The aim of neuromarketing is to understand not only articulable thoughts, but also subconscious ones that cannot be so readily expressed [3]. As neuromarketers collect large amounts of data and attempt to find the mystical “buy” button in the brain, personal thoughts that belong to individuals may not be so private anymore. Although neuroscience techniques such as fMRI used in neuromarketing are relatively safe and non-intrusive [5], damage done to individuals because of privacy infringements can be just as harmful. Freedom of religion and freedom of expression are widely known and accepted. Freedom of thought, although less acknowledged, is just as important. Freedom of thought is the right of an individual to have a distinct opinion or viewpoint. The Universal Declaration of Human Rights, adopted by the United Nations in 1948, guarantees this right to all individuals [9]. Although it may be unintentional, neuromarketing has the potential to infringe on the freedom of individuals to withhold (which is the largest difference between neuromarketing and older marketing strategies) and maintain private thoughts.

One of the key steps in addressing the ethical concerns of neuromarketing is realizing the need for transparency. Although extensive research on human behavior and decision-making has been done at research institutes, the applications of this research are primarily being explored in the private industry. Conflict of interest due to competition suggests that there is minimal sharing of neuromarketing techniques and knowledge between companies that conduct neuromarketing research [10]. Searching the term “neuromarketing” on PubMed gives a mere 38 hits (compare this to over 85,000 hits given by “Parkinson’s Disease”). Neuromarketing is an issue that has the potential to affect almost every American on a daily basis, and because of the possible ethical issues detailed above, it is important that these research methods and neuromarketing knowledge are monitored to ensure appropriate development of research methods and treatment of research participants.

Image courtesy of Ajtel

The need for transparency and the ethical implications of neuromarketing necessitate regulations and monitoring. Just as in the food industry [11], the field of neuromarketing can utilize self-regulation initiatives to protect consumer rights while pursuing their own agenda; this will also reduce the need for large, stringent government oversight. However, because of the serious implications of neuromarketing, it is prudent to monitor neuromarketing not only within companies, but also on a broader scope through governmental means. The Federal Trade Commission plays a role in overseeing laws regarding marketing and advertising [12]. The United States Department of Health and Human Services is responsible for protecting the health of all Americans [13]. The task of regulating neuromarketing requires knowledge about current neuroscience technologies as well as the ways in which businesses operate. Therefore, a new government agency that is supported by both of these larger agencies should be formed to ensure the proper ethical development of neuromarketing.

This new agency should create standardized regulations that emphasize the potential ethical implications of neuromarketing. Because of the specialized nature of neuromarketing, comprehensive training that outlines the importance and implications of neuromarketing should be required for those working directly with neuromarketing methods. Training modules should be developed by both neuroscientists and businesspersons, and the rights and interests of both consumers and companies should be considered. Although there is a fine line between fair encouragement and illegal deception, it is also important to consider the rights of companies as well. Within the context of a free market, businesses have a right to develop and sell products. Regulating neuromarketing within the private sector must balance the rights of private companies alongside the rights of the consumers. Research that is being conducted should also be monitored by this agency, which would act as a nonpartisan party between companies and consumers. Research regarding ethical questions such as “to what extent can neuromarketing affect and circumvent the ability to make reasonable and logical decisions?” and “what people groups are susceptible to neuromarketing, and how can we protect them?” should be carefully monitored and later integrated in order to continually regulate and reform this field.

Neuromarketing is limited, to a certain extent, by technology. At this time, explicit reading of minds is impossible because current neuroscience techniques like fMRI and EEG only allow for more general analysis of the brain and its functions. However, just as the rudimentary cell phone evolved into the sophisticated smartphone after a mere 20 years [14], the field of neuromarketing may also develop at a shocking rate. And if it does, it is important that regulations and measures are put into place before there are any serious consequences. One grim thought to consider is this: if neuromarketing finds a way to bypass rational thought, then will issues such as gambling, obesity, and alcoholism, (into which companies may indirectly invest billions of dollars [15]) become even more rampant?

Although neuromarketing has promising potential, the field may face opposition because of the belief that the main purpose of neuromarketing is to hijack the mind [16]. This may be the reason why neuromarketing research is banned in France [17]. However, current technology suggests that this ominous outcome is unlikely because the aggregate brain is highly complex, and external factors only play a partial role in influencing behavior. Additionally, just as a person can be influenced to make a poor judgment in purchasing a good, that person can also be influenced to make a healthy, beneficial decision. An agency that oversees neuromarketing research and self-regulation methods can flexibly prepare for the variable future of neuromarketing and work toward the best interests of companies and consumers. By properly regulating and monitoring neuromarketing to secure the rights of consumers without enforcing guidelines that are too strict on the free market, progress towards proper development of neuromarketing can be ensured.

References



1. Paul A. (2002). Company Uses Neuromarketing to Unlock the Consumer Mind. PRWeb. Retrieved from http://www.prweb.com/releases/2002/6/prweb40936.htm



2. Fisher CE, Chin L, & Klitzman R. (2010). Defining Neuromarketing: Practices and Professional Challenges. Harvard Review of Psychiatry, 18(4), 230–237. http://doi.org/10.3109/10673229.2010.496623



3. Voorhees T, Spiegel DL, & Cooper D. (2009). Neuromarketing: Legal and Policy Issues. A Covington White Paper. Retrieved from https://cov.com/files/upload/White_Paper_Neuromarketing_Legal_and_Policy_Issues.pdf



4. Introduction to Neuromarketing. (2016). ImpactHub. Retrieved from http://www.hubpraha.cz/en/event/introduction-to-neuromarketing/



5. What is fMRI?. UC San Diego School of Medicine. Retrieved from http://fmri.ucsd.edu/Research/whatisfmri.html



6. McClure SM, Li J, Tomlin D, Cypert KS, Montague LM, & Montague PR. (2004). Neural Correlates of Behavioral Preference for Culturally Familiar Drinks. Neuron. doi: 44(2):379-87



7. 45 CFR 76 - GOVERNMENTWIDE DEBARMENT AND SUSPENSION (NONPROCUREMENT). US Government Publishing Office. Retrieved from

https://www.gpo.gov/fdsys/granule/CFR-2004-title45-vol1/CFR-2004-title45-vol1-part76



8. Illinois Compiled Statutes. Illinois General Assembly. Retrieved from http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=2357



9. Universal Declaration of Human Rights. (1948). United Nations. Retrieved from http://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf



10. Bennett C. (2011). The Seven Sins of Neuromarketing. Prefrontal. Retrieved from http://prefrontal.org/blog/2011/04/the-seven-sins-of-neuromarketing/



11. Sharma LL, Teret SP, & Brownell KD. (2010). The Food Industry and Self-Regulation: Standards to Promote Success and to Avoid Public Health Failures. American Journal of Public Health. 100(2), 240–246. http://doi.org/10.2105/AJPH.2009.160960



12. Holt M. Five Areas of Government Regulation of Business. Demand Media. Retrieved from http://smallbusiness.chron.com/five-areas-government-regulation-business-701.html



13. Agencies and Regulations. American Nurses Association. Retrieved from http://www.nursingworld.org/Agencies-RegulatoryAffairs



14. Goodwin R. (2015). The History of Mobile Phones from 1973 to 2008: The Handsets That Made It ALL Happen. Knowyourmobile. Retrieved from http://www.knowyourmobile.com/nokia/nokia-3310/19848/history-mobile-phones-1973-2008-handsets-made-it-all-happen



15. Tobacco Industry Marketing. Center for Disease Control. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/marketing/



16. Morin C. (2011). Neuromarketing and ethics: a call for more attention and action to raise standards. Neuromarketing. Retrieved from http://neuromarketing.ning.com/profiles/blogs/neuromarketing-and-ethics-a-call-for-more-attention-and-action-to



17. Oullier O. (2012). Clear up this fuzzy thinking on brain scans. Nature. Retrieved from http://www.nature.com/news/clear-up-this-fuzzy-thinking-on-brain-scans-1.10127



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Lee, S. (2016). A Corner on the Neuromarket. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/09/a-corner-on-neuromarket.html

Placebo as Therapy: Context, Ethics, and Recommendations

By Somnath Das

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris of Summer 2016.

I am a Senior at Emory University and am currently pursuing a double major in Neuroscience and Chemistry. Currently, I am applying to medical school. My interest in healthcare lies primarily in understanding the behavioral motivations of patients as they navigate through various healthcare systems. I also wish to study how to effectively translate innovations powered by biomedical research into accurate health information for patients and optimized healthcare delivery. Neuroethics allows me to focus these interests onto patient dignity and rights when considering the role novel therapeutics and interventions in treatment. Studying this fascinating field has given me a perspective on the role deontological considerations play in both neuroscience and medicine as a whole. It is with this perspective that I hope to approach my patients with a balanced worldview, taking into account both individual rights as well as stakeholders and developers participating in a rapidly changing field. 

Placebo therapy is broadly characterized as the administration of an agent that possesses a physiologically inert effect. However, current research suggests that placebo in fact has observable therapeutic outcomes across a wide spectrum of disorders. Thus, placebo’s efficacy should be investigated thoroughly by researchers, ethicists, and physicians in order to evaluate and develop protocols to implement placebo therapy in an effective manner. It is necessary that researchers communicate to physicians and clinicians about the efficacy and rigor by which research has quantified placebo’s effect. In addition, training protocols must be developed such that physicians can safely implement placebo therapy in practice. Finally, the ethics of placebo should be carefully considered; a calculation of placebo ethics is presented in tandem with policy recommendations in this document.

Image courtesy of Wikicommons.

A robust body of recent literature has connected placebo administration to treatment of neurological and psychiatric disorders. Placebo therapy has been shown to modulate the rostral anterior cingulate cortex (rACC), whose connectivity with the periaquiductual gray (PAG) is important for endogenous opioid production and thus modulation of pain [1]. Administration of saline injection has been shown to modulate dopamine release in the dorsal striatum, which has important implications for patients with Parkinson’s disease [2]. A review by Irving Kirsch found that placebo demonstrated a significant confounding effect in many studies involving antidepressants suggesting placebo therapy’s efficacy for treating depression [3]. Karen Rommelfanger in an opinion article for Nature Neuroscience discussed placebo’s potential as a treatment for conditions that lack a standard of care, such as psychogenic movement disorders, highlighting both clinical evidence about its efficacy as well as ethical considerations [4]. It is thus important that research on the placebo effect continue to supplement what is a growing field in order to accurately and rigorously document its efficacy for clinical application.

Studies on placebo utilization by family medicine physicians have shown that this therapy is commonly recruited in practice. A study by Kermen et al. (2010) found that among their respondents, 56% had used placebo in clinical practice. The most common reason for doing so was “unjustified demand for medication,” and the majority of their respondents recommended prescribing placebo to patients over no treatment [5]. Educators seeking to implement novel therapies, particularly for neurological and psychiatric disorders, should investigate the feasibility of placebo training education. Not only should clinical data be emphasized, but also doctor-patient communication. Patient belief in therapy, and thus cognitive salience of placebo, has been shown to modulate therapeutic efficacy in PD patients [6]. Therefore, physicians seeking to implement placebo therapy must be trained in effective doctor-patient communication specific to how to best reassure their patients about placebo’s safety and effectiveness.

That said, there are various ethical considerations when deciding to use placebo. The role of deception presents a significant issue. However, research has shown that models of authorized deception do not affect the efficacy of placebo therapy [7]. Physicians prescribing placebo could also be accused of giving patients therapies which they know are inert, violating the physician-patient relationship. However, the study by Kermen et al. presented above in addition to a continuous volume of studies suggest that physicians do believe in the efficacy of placebo. In addition, as education about placebo therapy and development of guidelines increases over time, so will updates to professional understanding of mechanism of placebo as therapy.

There is a significant need to develop standardized guidelines for ethical and appropriate usage of placebo therapy. Studies have shown for example that genes may modulate the effectiveness of placebo [8]. Literature has documented placebo’s effectiveness in mental disorders where the patient’s ability to consent may be variable, such as schizophrenia [9]. As placebo is being explored in the context of various psychiatric disorders, the ability of patients to consent to placebo treatment should be actively explored. Finally, guidelines should include which types of placebos are appropriate for usage. Studies have quantified physician prescription of multivitamins, antibiotics, and titrated medications in order to administer placebo therapy. Prescription of impure placebo remains to be fully studied, as many studies assume pure placebo [10, 11]. Alternative therapies, such as medical marijuana and acupuncture, must also be considered under these guidelines. As usage of this therapy grows, so should guidelines pertaining to how to responsibly prescribe placebo without potential treatment side effects.

As researchers continue to test various principles of placebos, physicians and ethicists too must begin a dialogue about the future of its therapeutic implementation. Training guidelines for physicians, disseminated either through medical education curricula or physician seminars, should be created in order to safely implement placebo in clinical practice. These guidelines should include elements relevant to placebo research and also physician-patient communication. Alternative therapies and the use of impure placebo should also be considered. Ethical studies have shown that issues pertaining to deception may not necessarily be as significant as once thought and thus legal precedent for authorized deception may need to precede implementation of placebo in practice. As novel applications of placebo are being developed, the rights of the patient to consent must be explored. Consent models for placebo must be updated in order to account for the growing number of disorders, particularly psychiatric, that it is used to treat. The future of placebo therapy largely depends on a multi-faceted conversation between multiple scientific, legal, and ethical fields. However, this discussion is necessary in order to implement what is a novel and effective therapy for many patients across multiple spectrums of illness.

References

1. Bingel, U., J. Lorenz, E. Schoell, C. Weiller, and C. Buchel. "Mechanisms of Placebo Analgesia: Racc Recruitment of a Subcortical Antinociceptive Network." [In eng]. Pain 120, no. 1-2 (Jan 2006): 8-15.



2. de la Fuente-Fernandez, R., and A. J. Stoessl. "The Placebo Effect in Parkinson's Disease." [In eng]. Trends Neurosci 25, no. 6 (Jun 2002): 302-6.



3. Kirsch, Irving. "Antidepressants and the Placebo Effect." Zeitschrift Fur Psychologie 222, no. 3 (2014): 128-34.



4. Rommelfanger, Karen S. "Opinion: A Role for Placebo Therapy in Psychogenic Movement Disorders." Nat Rev Neurol 9, no. 6 (06//print 2013): 351-56.



5. Kermen, R., J. Hickner, H. Brody, and I. Hasham. "Family Physicians Believe the Placebo Effect Is Therapeutic but Often Use Real Drugs as Placebos." [In eng]. Fam Med 42, no. 9 (Oct 2010): 636-42.



6. Lidstone, S. C., M. Schulzer, K. Dinelle, E. Mak, V. Sossi, T. J. Ruth, R. de la Fuente-Fernandez, A. G. Phillips, and A. J. Stoessl. "Effects of Expectation on Placebo-Induced Dopamine Release in Parkinson Disease." [In eng]. Arch Gen Psychiatry 67, no. 8 (Aug 2010): 857-65.



7. Martin, A.L., Katz, J.. " Inclusion of authorized deception in the informed consent process does not affect the magnitude of the placebo effect for experimentally induced pain. Pain 2010 May;149(2):208-15. doi: 10.1016/



8. Hall, K. T., A. J. Lembo, I. Kirsch, D. C. Ziogas, J. Douaiher, K. B. Jensen, L. A. Conboy, et al. "Catechol-O-Methyltransferase Val158met Polymorphism Predicts Placebo Effect in Irritable Bowel Syndrome." [In eng]. PLoS One 7, no. 10 (2012): e48135.



9. Kinon, B. J., A. J. Potts, and S. B. Watson. "Placebo Response in Clinical Trials with Schizophrenia Patients." [In eng]. Curr Opin Psychiatry 24, no. 2 (Mar 2011): 107-13.



10. Harris, Cory S, and Amir Raz. "Deliberate Use of Placebos in Clinical Practice: What We Really Know." Journal of Medical Ethics (May 28, 2012 2012).



11. Louhiala, Pekka. "What Do We Really Know About the Deliberate Use of Placebos in Clinical Practice?". Journal of Medical Ethics 38, no. 7 (July 1, 2012 2012): 403-05.



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Das, S. (2016). Placebo as Therapy: Context, Ethics, and Recommendations. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/09/placebo-as-therapy-context-ethics-and.html

Digital Immortality of the Future – Or, Advancements in Brain Emulation Research

By Kathy Bui

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris of Summer 2016.

Kathy Bui is a 4th year undergraduate at Emory University, majoring in Neuroscience and Behavioral Biology and Psychology. She hopes to pursue a PhD in neurobiology after graduation. Her current interests include social justice topics of class disparities and human health rights. 

Introduction: “How do you want to be remembered?” 

The fear of our looming death has haunted us since human life began. It’s not hard to believe that the quest of human immortality has not changed since Gilgamesh’s quest for immortality in 22nd century BC. However, with the technological strides in conjunction with ambitious billionaires, the cure to death may be closer than we think. Life expectancy has been steadily increasing over decades, and yet, Americans seem to look forward to the inevitable prospect of immortality. According to a survey conducted by the Pew Research Center, 44% of Americans would want to extend their life to age 120 if given the opportunity [1, 2].

An integral part of human life is our biological death. We have sought to create artworks, legends, monuments that would outlive us – to show that we have made a mark on this world. In fact, they have: the Great Sphinx of Giza in Egypt, the Pantheon in Rome, and the Nanchan Temple in Wutai are only a few examples of the remaining buildings, surviving for centuries beyond their makers.

Interestingly enough, there is something else that has not only survived but is growing and expanding beyond expectation: the internet [3]. The internet allows us to preserve some of our memories by uploading photos onto our Instagram accounts, retaining videos of our adventures on YouTube, and keeping full-length conversations on our Gmail accounts. Now, what if we could upload all of our memories online – every meeting, every action, every decision? What if we could upload our brain – the compass of our thoughts and emotions – online? Let’s take it a step further as human innovation always does: digital immortality through brain emulation. 

Image courtesy Wikimedia.

According to Anders Sandberg, a research associate at Future of Humanity Institute at Oxford University, the idea is “to take a particular brain, scan its structure in detail at some resolution, construct a software model of the physiology that is so faithful to the original that, when run on appropriate hardware, it will have an internal causal structure that is essentially the same as the original brain” [4]. This may seem like bizarre science fiction. However, this goal may not so far off in the distant future. In 2011, Dmitry Itskov, a Russian entrepreneur, found the 2045 Initiative, a project working with a network of global scientists towards cybernetic immortality by “[creating] an artificial brain in which to transfer the original individual consciousness” [5, 6]. Massive computational power and multiple brain scans are rapidly developing these holistic large-scale computational brain models and algorithms, making it possible to upload the entirety of our memories onto the computer in the future [3, 7, 8]. Immortality, what once was a historical precedent failure, is becoming a feasible and inevitable feature to human life – which we should be allowed to pursue if we see death as a mass epidemic. 

Immediate ethical questions to consider 

It will not be our technology that will limit us but our ethical guidelines for brain emulation research. A string of ethical questions beg from this topic: 

• Should we be testing animals for brain emulation research? 




• With brain emulation research, animal experiments will be required. The progression of the research will most like start with in vitro experiments followed by experimentation of invertebrates and eventually, to primates before we can emulate human brains [4]. However, the question lies more with: how much suffering is necessary for this research? Quantifying and justifying suffering is difficult in itself and will vary depending on the study. Animal experimentation for brain emulation research should continue to fall under the current status quo animal research ethics guideline [10]. However, poor outcomes of the animal model brain emulation should halt human brain emulation research. 




• Who owns the brain emulation products? 




• In animal brain emulations, the company that funds the experiments owns the products, results, and intellectual property of the research. In human brain emulations, all parties involved: the company who owns the technology, the original, and the upload will inherently handle the memories but ownership should reside in the original and the upload, assuming both have the same consciousness. Technically, the company should only be able to use the information however they want (the same terms when we upload files on Google Drive) but they do not own it [11]. In a study, the participants and researcher should own that data after the study is complete.




• How do you upload a continuous stream of memories without the invasion of privacy? On the same train of thought, can the memories be sorted out? 




• By uploading a continuous stream of memories, the consenting person is waiving his/her right to the privacy of the memories. Human brain emulation requires the entirety of the memories, so it should not be dissected and picked apart [3]. Since people are the components of their experiences, there should not be experiences added or removed. Otherwise, there is the risk of the emulated brain not representing the original human. 




• Will everyone have an equal chance for immortality? 




• This boils down to the question of access. Realistically no, not everyone will have an equal chance, and certainly not when the technology is first available – especially if this research is privately funded [5, 6]. The rich will have access to digital immortality first, and this limited access will widen the gap between rich and poor [9]. Even if the technology became more affordable, the rich will continue to have the most advanced updates while the rest receive the trickle-down of the technology. However, this does not mean we should not continue to pursue this technology. If one group’s lives cannot be elongated, this does not mean we should not elongate the other group’s lives.




• Do the uploads get the same rights as humans? 




• Yes, the uploads should get the same rights as originals’ rights because they are the extension of the previous life. This is in the case of the originals who have their rights taken (ex: prison). 

Conclusion 

Transhumanism. Image courtesy of Gizmoto.

Overall, recommendations would be for further research into animal experiments before we continue the trajectory towards brain emulation. The best measurable way to see whether the animal’s self is simulated is based on its behaviors (i.e. do the emulated behaviors correspond to intact animal behaviors). Only then can we work towards human brain emulation and see whether the self can be cognitively simulated as well. The prospect of immortality is a heavy topic and should be handled cautiously, even if this debate decelerates our rapid advances towards immortality. If the animal shows depressive or self-harm tendencies, the experiment should halt immediately, following euthanasia – for humane reasons [12, 13]. The outcomes of the brain emulation research on animals will determine whether we should continue to proceed or ban this research. A poor prognosis in the animal model is a key indicator. If the outcomes are fatal or debilitating to the animal during the process of uploading memories, then we should ban brain emulation research. There is a chance for a good animal prognosis, yet a poor translational human prognosis. Of course, the first human experiment must be a success before brain emulation becomes commercially available. So, should brain emulation continue without missteps, then we should see this project to the end because humans will always continue the quest of immortality. Our goal should not decide whether we should ban human brain emulation but to take precautions to make sure the first human brain emulation is safe. 

In addition, federal regulations should specifically address and oversee the privately-funded research on brain emulation and the products of the experiments. There are currently no regulations for this research topic and the consequences [4]. Before the first successful human brain emulation, federal law should grant the uploads all of the rights that the original had, assuming that the upload behaves and thinks exactly the same way as the original. However, if the upload differs from the original, then there should be a period of adjustment to society, and federal law should give pardon to the uploads by giving them access to all the rights a law-abiding citizen has. We must assume the uploads are inherently good and must have rights; otherwise, we will be abusing their human rights. 

These are only a few of the immediate policies we should implement before we continue with the first human brain emulation. Of course, with the advent of the first emulated human brain, there will be further complications that we won’t be able to foresee no matter how much we debate; unfortunately, many of the cases against emulated human brains will have to set precedent to future federal policies. 

References 



1. Pew Research Center. 2013. Living to 120 and Beyond: Americans’ Views on Aging, Medical Advances and Radical Life Extension. Available at: http://www.pewforum.org/2013/08/06/living-to-120-and-beyond-americans-views-on-aging-medical-advances-and-radical-life-extension/ (accessed June 19, 2016).



2. Friedman, L. 2015. 'One of society’s greatest achievements' — in a simple chart of the past 175 years. Insider UK, June 19. Available at: http://uk.businessinsider.com/how-has-life-expectancy-changed-throughout-history-2015-6?r=US&IR=T (accessed June 19, 2016).



3. Parkin, S. 2015. Back-up brains: The era of digital immortality. BBC Future, January 23. Available at: http://www.bbc.com/future/story/20150122-the-secret-to-immortality (accessed June 19, 2016).



4. Anders Sandberg (2014) Ethics of brain emulations, Journal of Experimental & Theoretical Artificial Intelligence, 26:3, 439-457, DOI: 10.1080/0952813X.2014.895113



5. 2045 Initiative. 2012. 2045 Strategic Social Initiative. Available at: http://2045.com/ (accessed June 19, 2016).



6. Bolton, D. 2016. Russian billionaire Dmitry Itskov seeks 'immortality' by uploading his brain to a computer. Independent UK, March 14. Available at: http://www.independent.co.uk/news/science/dmitry-itskov-2045-initiative-immortality-brain-uploading-a6930416.html (accessed June 19, 2016).



7. Beloussov, S. 2016. Digital immortality: How to create an external copy of yourself. Beta News, February 26. Available at: http://betanews.com/2016/02/26/digital-immortality-how-to-create-an-eternal-copy-of-yourself/ (accessed June 19, 2016).



8. Than, K. 2006. The Ethical Dilemmas of Immortality. Live Science, May 23. Available at: http://www.livescience.com/10465-ethical-dilemmas-immortality.html (accessed June 19, 2016).



9. National Academy of Sciences. 2011. Guide for the Care and Use of Laboratory Animals. 8th ed. Available at: https://grants.nih.gov/grants/olaw/Guide-for-the-Care-and-use-of-laboratory-animals.pdf (accessed June 19, 2016).



10. Whittaker, Z. 2012. Who owns your files on Google Drive? CNET, April 24. Available at: http://www.cnet.com/news/who-owns-your-files-on-google-drive/ (accessed June 19, 2016).



11. NPR. 2012. What Animals Can Teach Humans About Healing. Available at: http://www.npr.org/2012/06/12/154523594/what-animals-can-teach-humans-about-healing (accessed June 19, 2016).



12. Yuan, X., & Devine, D. (2016). The role of anxiety in vulnerability for self-injurious behaviour: Studies in a rodent model. Behavioural Brain Research, 311, 201-209. doi:10.1016/j.bbr.2016.05.041



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Bui, K. (2016). Digital Immortality of the Future – Or, Advancements in Brain Emulation Research. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/09/digital-immortality-of-future-or.html

Embodied Cognition: What it means to "Throw like a Girl"

By Jenn Lee

Jenn Laura Lee is a PhD candidate in neuroscience at New York University. Her scattered neuroethics projects involve advancing harms reduction policies for illicit drug use and re-evaluating the ethics of animal experimentation.

While I tell myself now that I’m just “not the athletic type,” the reality is that I might have been. Back in middle school, I recall actually really enjoying track and field, basketball, and soccer. But at just the age when girls reach peak athletic shape, a socially-imposed understanding of “femininity” begins to forge a new, contrived relationship between one’s self and one’s body.

The rehearsal of gendered social performances run deep enough to mould even our most basic bodily movements. In Throwing like a Girl, Iris Young dissects this phenomenon through the philosophy of Simone de Beauvoir and Maurice Merleau-Ponty (who was, coincidentally, one of Simone de Beauvoir’s first romantic interests).

Many are familiar with de Beauvoir’s The Second Sex, in which she describes some of the structural biological differences between men and women that have perhaps led to female oppression. Maurice Merleau-Ponty, also a preeminent phenomenologist of the 40’s and 50’s, argued mainly for the primacy of embodiment – meaning that any sweeping claims about the nature of the external universe must first take into account our physical bodies and how they move, perceive, sense, and interact with the outside world. He would argue that if we want to study consciousness, we can’t only study the brain – we must concurrently strive to understand the basic sensorimotor phenomena which feed the brain everything it knows.

The concept of embodied cognition is taking off in cognitive neuroscience. The embodiment thesis suggests that “features of cognition... are deeply dependent upon characteristics of the physical body of an agent, such that the agent’s beyond-the-brain body plays a significant causal role, or a physically constitutive role, in that agent’s cognitive processing."

This is, of course, a hot topic in Artificial Intelligence (AI) research. Turing himself remarked that in order for AI to think and speak like a human, it would probably not only need heavy-duty cognitive processing power; it would require fully human-like peripheral sensorimotor capabilities (touch, sight, movement), as well.

Image courtesy of Pixabay

Drawing on basic principles of embodied cognition and feminist theory, Young’s hypothesis suggests that despite the purely physical, genetically-encoded differences between the sexes, one’s being a woman prevents her from achieving her full physical potential because, to some degree, she is constantly engaging in cognitive self-objectification.

Her proposal is elegant, and complete: Women are used to being looked at and acted upon, like objects rather than subjects; and this conditioning changes even our most fundamental cognitive processing at a basic, sensorimotor level. We have been conditioned to see ourselves in relation to the objects of our environment, rather than free and autonomous agents within it.

When, for instance, a ball is thrown to me, I have a tendency to think that it is being thrown at me, and will run, duck, and hide, instead of trying to catch it. Or when girls learn to ride bikes or ski, they often see themselves as the object of a motion, rather than its originator.

Absolute strength aside, women are less likely than men to throw a ball or lift a box with our full weight and corporal potential because we are conditioned to believe we are delicate objects; we have been taught to constantly second-guess our chances of successfully completing physical tasks. Through social feedback, we become cognitively confined by our own bodies. Rather than seeing the body as an avatar through which we can achieve our ends, we perceive the body as a hindrance which must be overcome.

The cognitive component to Young’s argument cannot be overstated. Our relationship with our body is critical to determining how we even so much as perceive the world around us. Consider recent neuroscience papers which demonstrate that visual processing is modulated by active flight in drosophila (fruit flies). This could essentially demonstrate how the very act of dynamically controlling our bodies changes the way we visually process the world in real-time.

Recent fMRI studies have moreover shown how the planning and perception of actions may be influenced by one’s body posture. Popular science outlets have moreover found clickbait fodder in studies showing that “power posing” (assuming a broad, upright posture of dominance) produced lower cortisol and higher testosterone levels in both men and women, leading to socially advantageous behavioral changes. The implications of this finding are particularly disturbing when paired with the observation that women are rewarded for taking up as little space as possible in social situations, both literally and metaphorically. I shudder to think of the cognitive effects that being taught to “sit like a lady,” “walk like a woman,” and “throw like a girl” might have on the way a woman perceives her sense of self, her body, and the obstacles and challenges in her environment. It is especially jarring to think that the effects of being taught to physically shrink oneself might become so deep-rooted throughout childhood as to impact cognition at the level of primary sensory perception and sensorimotor modulation.

Young’s paper touches on the related idea of the “male gaze” and its equally profound effects on bodily comportment. In my track and field days, I can certainly recall girls holding back in shot put simply because they were afraid of how it would look to other people (full physical exertion is deemed masculine and therefore unattractive). Perhaps owing to this constant third-person scrutiny, Young suggests that young girls are typically conditioned to be “field-dependent” learners, in contrast to their field-independent male counterparts.

Image courtesy of PublicDomainPictures

The idea of field dependence as cognitive style was one of the earliest of its kind, advanced by Herman Witkin in the 60’s. Empirical support for this gendered trend is quite extensive. Women are more likely to perceive themselves as continuous with their spatial environment, while men tend to perceive themselves as independently-moving, central agents within it (think: Sims character vs. first-person shooter). Unsurprisingly, this cognitive style suggests women are conditioned to be heavily context-driven when performing basic tasks. For instance, female performance in a clerical task seemed to be far more affected  by whether their examiner appeared “approving” or “disapproving” throughout, reflecting a “greater attentiveness to the attitudes of those around them.”

I’ve moreover often wondered why horse-back riding was such a female-dominated sport, and Young’s essay shed light on this for me. The classic Freudian explanation is that young girls crave the ability to tame and control a wild, powerful animal (representative of the id). Girls (lacking a phallus, and therefore hopelessly incomplete) are attracted to and wish to possess powerful, phallic creatures like horses.

Young’s theory might explain this “innate” draw in a much more scientific (and less misogynistic) way. If it’s true that women have a conditioned tendency to see themselves in relation to the actors of their physical environment, then horseback riding is quite naturally appealing to young girls, being one of the only “empathetic” solo sports in which one must position oneself in relation to another agent in order to succeed (coaxing the horse to change direction and praising it constantly for achieving one’s ends). Contrast this to an impersonal sport like dirt-bike riding, wherein women are more likely to feel like the object of a movement, rather than its first-person initiator.

To what degree does society shape bodily comportment, which then shapes cognition, and vice versa? In general, we need to do a better job addressing the social roots of gendered trends in cognition. Similarly, embodied cognition can help inform social analysis in ways that are surprising and seldom explored. As the themes of neuroethics expand to encompass those of neuroexistentialism (addressing questions of choice, free-will, and authenticity), fascinating essays like Young’s are a good reminder that critical social theory will play an increasingly prominent role in neuroscientific inquiry.

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Lee, J. (2016). Embodied Cognition: What it means to "Throw like a Girl". The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/09/embodied-cognition-what-it-means-to.html

Neuroethics Network and DBS

By Ethan Morris

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris of Summer 2016.

Ethan Morris is a rising undergraduate senior at Emory University, majoring in Neuroscience and Behavioral Biology with a minor in History. Ethan is a member of the Dilks Lab at Emory and is a legislator on the Emory University Student Government Association. Ethan is from Denver, Colorado and loves to ski.  

One thought-provoking panel at the Paris Neuroethics Network discussed deep-brain stimulation, or DBS. DBS is a relatively novel treatment in which surgeons implant an electrode deep within the brain. When the electrode is turned on, it produces a current that has been shown to alleviate symptoms of Parkinson’s disease. Various studies have provided compelling evidence that DBS may also be an effective treatment for psychiatric disorders, such as major depression, especially when other treatment options are exhausted.

The conference panelists discussed the ethical concerns about DBS, in particular the idea of the “true self” and whether this is affected by DBS. Studies have shown that after DBS surgery, patients can experience personality changes, which has led to some concern that DBS threatens personal identity. The concept of personal identity is nebulous, but some believe that too stark a contrast in personality between pre- and post-DBS constitutes a violation of identity. As was raised by the panelists, this purported identity change may actually be welcomed by the patient who feels their “true self” has been unlocked; however, families may also feel their loved one is no longer the same person. One of the panelists, Dr. Sabine Müller, a German philosopher, firmly believes that DBS treatment should proceed unencumbered by ethical concerns about loss of self. Müller argued there is an erroneously assumed connection between reports of feeling like a different person and metaphysical classifications of personal identity. Müller contended that ethicists overstate negative personality changes, while overlooking accounts of DBS helping patients rediscover themselves. While she did not state it outright, Müller’s analysis reflects her stance as a consequentialist on this issue– she thinks that DBS does not change identity, and consequently, the beneficial outcomes of DBS should outweigh any metaphysical concerns.

Image courtesy of Pexels.com

Dr. Müller argued that the issue with DBS is not a loss of the true self, but rather how people view changes in personality and personal narratives, more generally. One can also imagine that human identity can be static, while there are others who believe that identities are dynamic. Perhaps patients who experience positive changes view them as part of their natural dynamic narrative, while families who are unnerved by the changes see them as a departure from their expectation of others’ stability. The discussion also reminded me of a class discussion on aging and identity, during which there was a debate over whether it is appropriate to say that a person suffering from dementia is no longer the same person. One interesting concept raised in class was that the behavioral and personality changes that coincide with aging elicit these emotional reactions (i.e. they are not the same anymore) because of the rate of change. It is possible that DBS raises ethical concerns about identity because it so rapidly changes the personality of the patient after one procedure. Perhaps humans do not expect others to remain static, but they expect and can comprehend a gradual (i.e. natural) change over time. Either way, Müller argues that these metaphysical exercises are secondary considerations to the beneficial aspects of DBS, including relieved symptoms and, in some cases, positive personality changes.

Furthermore, Müller argued that different people cannot inhabit the same body in one lifetime. Interestingly, this may mean Müller subscribes to a version of Cartesian dualism, in which the self is dissociated from the brain, which theoretically means you could change the brain without changing the self. However, because the concept of the “true self” is elusive and differentially defined, it may not be possible to prove that the brain contains our true selves. Given that scientists do not fully understand the mechanisms by which DBS works. In a review article, Birdno and Grill (2008) highlighted possible DBS mechanisms, including significant changes in cellular activity. If DBS were found to appreciably change brain chemistry, it would be fair to suggest DBS changes our brains. And if the brain is the source of behavior, personality, and perhaps self-identity, then it may not be so trivial that DBS makes physiological changes to the brain. It could mean that these physiological changes cause a shift from the prior self with one kind of brain chemistry to a new self with a different kind of brain chemistry.

Despite the concerns about DBS and identity, I agree with Müller in taking a consequentialist approach to DBS, with a couple significant caveats. Those suffering from Parkinson’s disease, major depression, and other disorders often experience precipitous declines in quality of life that cannot be addressed with other treatments. DBS is a beneficial strategy to alleviate debilitating symptoms, and should continue to be used. However, patients must understand the implications of DBS, even if it is a reversible procedure. By potentially implicating their brain chemistry, they are at risk for changing their personality, either positively or negatively, and patients should be aware of this risk. While Müller argued that detailed pre- and post-surgery consent forms were overcomplicating the procedure, I believe this minor inconvenience is worth the trouble. Additionally, doctors and surgeons must take into account the societal views on personality change. Müller may think the jump from personality change to personal identity change is unwarranted, but the public may not. It is possible that the general public associates the true self with some measure of personality, whether dynamic or static. If people view others’ identity as static, then DBS may upset this expectation, while if people view others’ identities as dynamic, then DBS may accelerate natural change and still be uncomfortable. Ultimately, the concerns over family and societal expectations should not trump the needs of the patients; if patients assume the inherent risks of DBS with full informed consent, they should have the opportunity to better their lives.

References



Birdno, M.J., W.M., Grill. 2008. Mechanisms of deep brain stimulation in movement disorders as revealed by changes in stimulus frequency. Neurotherapeutics, 5(1): 14-25.



Schermer, M. 2011. Ethical issues in deep brain stimulation. Frontiers in Integrative Neuroscience, 5: 17.



Sironi, V.A. 2011. Origin and evolution of deep brain stimulation. Frontiers in Integrative Neuroscience, 5: 42.



Wrobel, S. 2015. Flipping the switch: Targeting depression’s neural circuitry, Emory Medicine, Spring. Available at: http://emorymedicinemagazine.emory.edu/issues/2015/spring/features/brain-hacking/flipping-the-switch/index.html (accessed July 6, 2016).



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Morris, E. (2016). Neuroethics Network and DBS. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/09/neuroethics-network-and-dbs.html

“It’s like it’s not her anymore.”

By Sunidhi Ramesh

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris of Summer 2016.

Sunidhi Ramesh, an Atlanta native, is entering her third year at Emory University where she is double majoring in Sociology and Neuroscience and Behavioral Biology. She plans to pursue a career in medicine and holds a deep interest in sparking conversation and change around her, particularly in regards to pressing social matters and how education in America is both viewed and handled. In her spare time, Sunidhi is a writer, bridge player, dancer, and violinist.

Picture this. A patient struggling with depression for almost twenty years undergoes her last resort treatment: deep brain stimulation (DBS). It is radical, invasive— somewhat new of a procedure to the point where only a few surgeons are skilled enough to perform it. But she decides to go through with it. And when it’s over, she can smile again, find motivation again. She feels brand new.

But her family isn’t so optimistic. This isn’t the woman they waved goodbye to before the surgery. This woman is different. It’s like it’s not her anymore.

So what do the surgeons do? Remove the implant and bring back the pre-surgery depression? Well, that’s not exactly what our patient wants. Keep the implant and leave her as-is? Well, her family wouldn’t be too happy with that.

What was actually done during the DBS procedure? Did we restore our patient’s original functioning and simply bring to light her true self? Or did we mask her true self with an alternate personality? What is the true self, anyways? Does it exist? And if it does, where can we find it?

This is the nature of the “true self” debate.

In a time when procedures such as DBS exist as viable treatments for mental illness, the nature of personal identity and its continuity are topics that must be questioned and debated. Thus, these issues were the topic of conversation at the Pitié-Salpêtrière Hospital during the Neuroethics Network Conference in Paris, France. (The ideas and questions that I consider throughout this piece were sparked by the presentation, panel, and discussion from this conference.)

The idea of identity permeates every form of the human experience. In the criminal justice system, we rely on the fact that each person holds only “one identity” and that that identity is responsible for its own actions. In the educational system, we invest in cultivating, developing, and praising “one identity”; in our social circles, we expect to interact with the single identities of the people we know and love.

And, most importantly, our individual morals, rights, and thoughts revolve around our perceptions of our own identities.

But we also hold a double standard. We would all like to think that our identities are complex.

Image courtesy of Pixabay

I’m a different person when I’m hungry. That time I snapped at my brother? I was having a rough day. I wasn’t being myself. That day I got rejected from ten universities? The girl that existed that week wasn’t really me.

We make excuses for our identities by breaking it into distinct pieces. It’s only human. But how does this play into the idea of a “true self”? Is it all these identities averaged together into one? Is it one piece more than another? What is it?

Furthermore, in a medical sense, do we want to engage in procedures or interventions that pose as a threat to a patient’s personal identity? That contain the risk or side effect of this patient waking up as “another person” or, effectively, a “healthy stranger”?

All of these arguments are salient and important. But let’s return to the original case. We have a patient who is satisfied with her procedure accompanied by a family who feels as if they no longer recognize her.

In The Illness Narratives: Suffering, Healing, and the Human Condition [1], author Arthur Kleinman begins to describe the phenomenon of illness. He argues that the way a person experiences and understands illness is different from how it is perceived by the people around her. To do so, he illustrates the example of a father who is plagued by pain all over his body. The doctors are unable to find a cause for it, and he has no physical symptoms. His motivation, drive, emotionality, and interests begin to change as a result of his illness; but his family refuses to believe that his suffering is real, and the man endures a form of emotional pain and abuse from his family because of it.

In this real-life scenario, the family is in a position of power. They have the right to determine whether or not the father is a changed man, whether or not he is in pain, and whether or not his illness is real. The father has no say in the matter. He is simply a patient at the will of the people around him.

Shift back to our DBS patient. Does her family have a right to ask for the treatment to be reversed on the basis of her becoming a “different person”? Considering that she has been struggling with this illness for almost two decades, can we trust that the family remembers what she was like before depression? In that case, perhaps she is not becoming a different person after all. Perhaps she is simply becoming the person she was before the illness overcame her. Or perhaps she’s just getting to become the person she has never been able to be; perhaps she has been depressed her entire life.

When we start questioning the nature of identity and individuality, we should also consider beginning to place more control in the patient’s hands. What keeps DBS implants from being manually controlled by the patient? Is it unreasonable to allow implants to be shut off by the switch of a button—a button that only the patient can control? At least then, the patient has somewhat of a say as to whether or not they enjoy or desire the identity changes that the treatment creates. (However, it is important to note that this may prove to be more complicated than it sounds. For one, DBS has different “effects on various symptoms, and different implications for patients’ needs, expectations and wishes. [2]” This, at the least, implies that it will be difficult for the patient and the doctor to properly quantify any changes in symptomology before and after DBS [3]. Furthermore, our knowledge of DBS and how exactly it works is extremely limited; giving the patient control over their treatment can lead to unanticipated consequences and malfunctions. This has happened before.)

More research needs to be done. But if that’s not a viable solution, another needs to be determined, discussed, and put into place.

Whatever the case, considerations of a patient’s autonomy, identity, and choice must be accounted for in any medical setting such as this one. Although a family’s opinion is important and vital in determining the patient’s own comfort and emotionality, the needs and opinions of the family must be set aside in the face of the patient’s own.

References

1. Kleinman, A. (1988). The illness narratives: Suffering, healing, and the human condition. Basic books.



2. Hariz, G. M., Limousin, P., & Hamberg, K. (2016). " DBS means everything-for some time". Patients' Perspectives on Daily Life with Deep Brain Stimulation for Parkinson's Disease. Journal of Parkinson's disease, 6(2), 335.



3. Hariz, G. M., Limousin, P., & Hamberg, K. (2016). " DBS means everything-for some time". Patients' Perspectives on Daily Life with Deep Brain Stimulation for Parkinson's Disease. Journal of Parkinson's disease, 6(2), 335.



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Ramesh, S. (2016). “It’s like it’s not her anymore.” The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/09/its-like-its-not-her-anymore.html