What can neuroethicists learn from public attitudes about moral bioenhancement?

By Peter Reiner

Dr. Reiner is Professor and co-founder of the National Core for Neuroethics at the University of British Columbia where he is a member of the Department of Psychiatry and the Centre for Brain Health. Dr. Reiner began his research career studying the cellular and molecular physiology of the brain, with particular interests in the neurobiology of behavioural states and the molecular underpinnings of neurodegenerative disease. In 1998, Dr. Reiner became President and CEO of Active Pass Pharmaceuticals, a drug discovery company that he founded to tackle the scourge of Alzheimer's disease. Upon returning to academic life in 2004, Dr. Reiner refocused his scholarly work in the area of neuroethics, co-founding the National Core for Neuroethics with Dr. Judy Illes in 2007. Dr. Reiner has championed quantitative analysis of public attitudes towards diverse issues in neuroethics including the propriety of cognitive and moral enhancement, the contours of autonomy in the real world, and the neuroethical implications of Technologies of the Extended Mind.

Moral behavior is fundamental to human society. Wherever one goes on the planet, one finds a set of norms that guide behavior, and following these norms is a basic tenet of peaceful coexistence with one’s fellow humans. Despite abundant evidence that the arc of human history trends towards decreased violence (Pinker, 2011), a proxy for moral behavior, scholars have suggested that society might be better off were we to enhance our moral capacities, and that using biological methods to do so is warranted (Douglas, 2008; Persson and Savulescu, 2008). This has engendered a vigorous debate that goes beyond the usual divide between bioconservatives and technoprogressives (Reiner, 2013a); in this arena, even ardent proponents of enhancement technologies have registered dissent (Harris, 2010).

The debate has been ongoing for nearly a decade, with no resolution in sight. In an effort to add a new voice to the discussion, Jona Specker and Maartje Schermer of Erasmus University joined me in querying the public about the issue. Our results are forthcoming in the journal Neuroethics (Specker et al., 2017), and I won’t steal our thunder by reviewing the entirety of our results. What I want to highlight here is our key finding – that the public overwhelmingly found moral bioenhancement to be deeply problematic.

Image courtesy of Flickr user Victor.

Our experimental design was intended to make acceptance as likely as possible: we chose an essentially non-controversial form of immoral behavior – bullying – as our target, thereby largely sidestepping the unresolvable issue of which moral framework should be used when considering moral bioenhancement. Moreover, we strove to make the biological treatment as innocuous as possible by describing the use of the natural hormone oxytocin as a means of increasing empathy. The experiment involved both quantitative and mixed-methods survey methdologies (Reiner, 2013b); all respondents read a vignette that described a child in school who had been a bully, but half the respondents read about a treatment program that involved oxytocin use, while the other half read about a treatment program that involved a video game. When asked whether they thought it was a good idea for the bully to participate in a program that used oxytocin as a moral bioenhancer, they resoundingly objected; unsurprisingly, they were no more enthusiastic when the program was described as mandatory. In contrast, there was widespread endorsement of the use of the video game as a means of moral enhancement. It is clear from further analysis of the data that the public welcomes moral enhancement by means of appealing to reason, but they recoil at the prospect of moral bioenhancement in large part because it is reasons-bypassing. Thus, the results provide empirical support for a proposition that Farah Focquaert and Maartje Schermer have previously put forth: means matter morally (Focquaert and Schermer, 2015).

Our study is but one way of exploring the issue, and is open to a variety of critiques; given the tenor of the debate, we fully expect both roses and arrows to arrive at our doorstep. To those who have an interest in the topic, reading the published paper will give you a sense of the full range of its implications.

Image courtesy of Flickr user

US Census Bureau.

What I want to highlight here is not just the results of our study, but rather the importance of querying the public on this issue. In my view, the question of moral bioenhancement is a paradigmatic instance in which understanding public attitudes is critical. While some issues in the field of neuroethics may sometimes seem arcane, changing the mores of society – really, a form of social engineering – is not to be embarked upon lightly. Morality is a highly personal property of societies, and as is evident by the vehemence of the culture wars, is one that many people feel strongly about. The dangers inherent in moral bioenhancement are not limited to the usual side effects of pharmaceuticals; the public also perceives danger in the instrumental bypassing of the sort of moral skill development that has been valorized in the virtue ethics tradition.

Pragmatic considerations also apply. For if there exists a yawning gap between the learned opinion of philosophers and the sentiments of the general public – if the very people whose mores are to be modified reject the approach – then not only must one overcome the normal regulatory restraints on pharmaceutical development but also the desire of the public to use such means of moral enhancement.

There is one final peril worth contemplating. At a moment in history when even in mature democracies autocratic sentiments are on the rise, suggesting that we engage in a form of social engineering that runs counter to public opinion is surely ill-advised.

References

Douglas T (2008) Moral Enhancement. Journal of Applied Philosophy 25:228–245.

Focquaert F, Schermer M (2015) Moral Enhancement: Do Means Matter Morally? Neuroethics 8:139–151.

Harris J (2010) Moral Enhancement and Freedom. Bioethics 25:102–111.

Persson I, Savulescu J (2008) The Perils of Cognitive Enhancement and the Urgent Imperative to Enhance the Moral Character of Humanity. Journal of Applied Philosophy 25:162–177.

Pinker S (2011) The Better Angels of Our Nature. Viking.

Reiner PB (2013a) The Biopolitics of Cognitive Enhancement. In: Cognitive Enhancement: An Interdisciplinary Perspective (Hildt E, Franke A, eds), pp 189–200. Springer Science+Business Media.

Reiner PB (2013b) Experimental Neuroethics. The Neuroethics Blog Available at: http://www.theneuroethicsblog.com/2013/11/experimental-neuroethics_5.html [Accessed January 19, 2013].

Specker J, Schermer M, Reiner PB (in press) Public attitudes towards moral enhancement: evidence that means matter morally. Neuroethics.

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Reiner, P. (2017). What can neuroethicists learn from public attitudes about moral bioenhancement? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2017/08/what-can-neuroethicists-learn-from_25.html

A Feminist Neuroethics of Mental Health

By Ann E. Fink

Ann Fink is currently the Wittig Fellow in Feminist Biology at the University of Wisconsin–Madison, with an appointment in Gender and Women’s Studies and concurrent affiliations with Psychology and the Center for Healthy Minds. Her research in cellular and behavioral neuroscience has appeared in the Journal of Neuroscience, Journal of Neurophysiology, PNAS and other journals. Ann’s interdisciplinary work addresses the ethics of neuroscience in relation to gender, mental health and social justice. 

Emotionality and gender are tied together in the popular imagination in ways that permeate mental health research. At first glance, gender, emotion, and mental health seem like a simple equation: when populations are divided in two, women show roughly double the incidence of depression, anxiety, and stress-related disorders^1-3. Innate biological explanations are easy to produce in the form of genes or hormones. It could be tempting to conclude that being born with XX chromosomes is simply the first step into a life of troubled mood. Yet, buried in the most simplistic formulations of mental illness as chemical imbalance or mis-wiring is the knowledge that human well-being is a shifting, psychosocial phenomenon. Learning and memory research offers a treasure trove of knowledge about how the physical and social environment changes the brain. Feminist scholarship adds to this understanding through critical inquiry into gender as a mode of interaction with the world. This essay explores how a feminist neuroethics framework enriches biological research into mental health. 

Problems with “Biology-from-birth” stories 

What if understanding gender and health isn’t a tale of two gonads (or genitalia, or chromosomes)? The primary theoretical problem with applying binary biology to health is essentialism^4,5, an oversimplified view of gender as comprising two distinct groups of people separated by innate and static biological traits. Feminist neurobiology counters this view with the observation that gender, a complex biopsychosocial phenomenon, cannot be reduced to dimorphism. This is illustrated by work from neuroimager Daphna Joel indicating that brains (unlike most genitalia) live happily in the land of intersex. Joel proposes a “brain mosaic”: human brains are a hodgepodge of statistically “male”-biased, “female”-biased, and neutral characteristics, rather than reflecting two categories⁶. Similarly, psychologist Janet Hyde demonstrates that genders are more alike than different in most cognitive and behavioral characteristics⁷.

The different components of biological sex.

Image courtesy of Wikimedia Commons.

What about those characteristics that differ by crude biological measures of sex? To ignore binary health disparities could be irresponsible. This reasoning precipitated the 2015 NIH mandate to study “sex as a biological variable”⁸, a corrective for the exclusion of “female” tissues and organisms from prior biomedical research. This move has in turn raised questions about what it means to properly study sex, and what, if anything, such research has to do with gender^9,10. The problem: sex and gender represent complex, interacting outcomes of social and biological forces. The first danger of essentialism is, therefore, to scientific knowledge in its own right. Other potential forms of harm then emerge from this oversimplification.

One danger of “biology-from-birth” stories is the possibility of iatrogenic (arising from medical care) disparities in health arising from inappropriate treatment differentials. As an example^9,10 the hypnotic drug zolpidem is cleared more slowly, on average, from women’s bodies compared to men’s, leading to concerns about inappropriate dosing. This gender difference, however, is mediated by weight, which correlates with gender. Potential harm and benefit emerge from this example. Dosing by gender risks overdosing men who weigh less than average, and ineffectively dosing women who weigh more than average. To base decisions on gender, rather than directly predictive indicators, in such cases might constitute negligence. This concern is amplified for people who do not fit neatly into binary categories of sex/gender.



Mental illness labels raise unique questions about autonomy and psychological competence. Furthermore, the definition of psychological disorders is particularly entangled with gender roles. Innate biological explanations risk activating stigma¹¹ by framing mental illness as static and disqualifying, and equating susceptibility with inferiority. The interactions of gendered stigma and mental health stigma can also deliver a double-hit of marginalization¹². The medico-social risks of stigma and assessments of incompetence include undermined consent, patient autonomy, and bodily integrity, as seen, for instance, in the dismal and ongoing justification of coerced sterilizations (tellingly, first labeled “asexualization”¹³). In a more subtle example, one suspected reason for women’s disproportionate cardiovascular mortality is their more frequent referral to psychiatrists than cardiologists (e.g. [14]).

Image courtesy of Wikimedia Commons.

If essentialist categories of identity and mental illness pose a threat to the health and autonomy of pathologized groups, a related risk is the justification of ongoing inequities and violence in larger social structures. Early-life maltreatment and lifelong adversity are major additive risk factors for poor psychological and physical health^15,16; these vary by gender and other aspects of social identity^17,18. Economic instability follows suit: a 2016 study links the gender wage gap to mood disorders¹⁹. To willfully ignore gendered, racialized or otherwise targeted harm in assessing health risk is to tacitly condone such harm. A feminist neuroethics recognizes the need to address social causes of biological susceptibility. 

The future of gender, neurobiology and mental health 

Feminist neurobiology avoids the pitfalls of simple, untenable “biology-from-birth” explanations. Rippon et al.’s guidelines for sex/gender research in neuroimaging⁴ are broadly applicable: their framework takes into account gender similarities (“overlap”) and brain mosaicism, recognizing brains as the ever-changing material substrates for equally dynamic mental states and social interactions (“entanglement”). They also call for improved experimental design, analysis²⁰, and interpretation. Feminist neuroethics respects historicity in science, acknowledging prior harm and proposing restorative and protective measures²¹. Feminist ethics can also protect against other forms of biological essentialism, including deterministic concepts of mental capacity. In agreement with philosopher Helen Longino’s formulation of science as a social endeavor requiring participation by a representative community²², feminist analyses acknowledge that mental health represents a continually debated set of norms.

Finally, a feminist neuroethics incorporates social causality and responsibility into biobehavioral health. Its guiding principle is a sustained attention to the problems of power, violence, and inequality that are so readily buried in reductionist research models. This view adds to mental health research by asking: 1) what interventions curb the staggeringly gendered experience of sexual and intimate partner violence²³ or the exposure to stress and deprivation that contribute to both social stratification and mental illness?, and 2) what are the neurobiological effects of, and remedies for, marginalization and interpersonal violence? (for starters, see: 24-26). A feminist neuroethics invokes biology as an enquiry into a dynamic world, embraces ambiguity, and promises a more nuanced and valuable knowledge of human health. 

References

1. Altemus, M., N. Sarvaiya, and C.N. Epperson. 2014. Sex differences in anxiety and depression: clinical perspectives. Frontiers in Neuroendocrinology 35(3): 320-330. 

2. Steel, Z., C. Marnane, C. Iranpour, et al. 2014. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. International Journal of Epidemiology 43(2): 476-93. 

3. Kessler, R. C., P. Berglund, O. Demler, et al. 2005. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):593–602. 

4. Rippon, G., R. Jordan-Young, A. Kaiser, and C. Fine. 2014. Recommendations for sex/gender neuroimaging research: key principles and implications for research design, analysis, and interpretation. Frontiers in Human Neuroscience 8: 650. 

5. Haslam, Nick, and Jennifer Whelan. 2008. Human natures: Psychological essentialism in thinking about differences between people. Social and Personality Psychology Compass 2, no. 3 (2008): 1297-312. 

6. Joel D, Berman Z, Tavor I, et al. (2015) Sex beyond the genitalia: The human brain mosaic. PNAS 112(50): 15468-15473. 

7. Hyde, J.S. 2005. The gender similarities hypothesis. American Psychologist 60: 581-592. 

8. Clayton, J. A., and F. S. Collins. 2014. Policy: NIH to balance sex in cell and animal studies.  Nature 509 (7500):282-3. 

9. Richardson, S. S., M. Reiches, H. Shattuck-Heidorn, et al. 2015. Opinion: Focus on preclinical sex differences will not address women's and men's health disparities.  Proc Natl Acad Sci USA 112 (44):13419-20. 

10. Ritz, S.A., D.M. Antle, J. Cote, et al. 2014. First steps for integrating sex and gender considerations into basic experimental biomedical research. The FASEB Journal 28: 4-13. 

11. Rusch, N., A. R. Todd, G. V. Bodenhausen, and P. W. Corrigan. 2010. Biogenetic models of psychopathology, implicit guilt, and mental illness stigma. Psychiatry Research 179(3): 328 – 332. 

12. Koenig, Anne M., and Alice H. Eagly. 2014. Extending Role Congruity Theory of Prejudice to Men and Women With Sex-Typed Mental Illnesses. Basic & Applied Social Psychology 36 (1):70-82. 

13. Stern, A. M. 2005. Sterilized in the name of public health: race, immigration, and reproductive control in modern California.  Am J Public Health 95 (7):1128-38. 

14. Maserejian, N. N., C. L. Link, K. L. Lutfey, et al. 2009. Disparities in physicians' interpretations of heart disease symptoms by patient gender: results of a video vignette factorial experiment.  J Womens Health (Larchmt) 18 (10):1661-7. 

15. Cohen, S., D. Janicki-Deverts, and G. E. Miller. 2007. Psychological stress and disease.  JAMA 298 (14):1685-7. 

16. Felitti, V. J., R. F. Anda, D. Nordenberg, D. F., et al. 1998. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.  Am J Prev Med 14 (4):245-58. 

17. Berger, M., and Z. Sarnyai. 2015. "More than skin deep": stress neurobiology and mental health consequences of racial discrimination.  Stress 18 (1):1-10.  

18. Westfall, N. C., and C. B. Nemeroff. 2015. The Preeminence of Early Life Trauma as a Risk Factor for Worsened Long-Term Health Outcomes in Women.  Curr Psychiatry Rep 17 (11):90. 

19. Platt, J., S. Prins, L. Bates, and K. Keyes. 2016. Unequal depression for equal work? How the wage gap explains gendered disparities in mood disorders.  Soc Sci Med 149:1-8. 

20. Fine, Cordelia, and Fiona Fidler. 2015. Sex and Power: Why Sex/Gender Neuroscience Should Motivate Statistical Reform. In Handbook of Neuroethics, ed. Jens Clausen and Neil Levy, 1447-1462. 

21. Chalfin, M. C., E. R. Murphy, and K. A. Karkazis. 2008. "Women's neuroethics? Why sex matters for neuroethics."  Am J Bioeth 8 (1):1-2. 

22. Longino, Helen E. 1990. Science as social knowledge : values and objectivity in scientific inquiry: Princeton, N.J. : Princeton University Press. 

23. Smith, S.G., J. Chen, K.C. Basile, L.K., et al. (2017). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Downloaded on 8/4/2017 from https://www.cdc.gov/violenceprevention/nisvs/summaryreports.html 

24. Sapolsky, R.M. (2005) The Influence of Social Hierarchy on Primate Health. Science 308 (5722):648-52.  

25. Cacioppo, JT et al. (2011) Social isolation. Annals of the New York Academy of Sciences, 1231: 17–22. 

26. Hackman, DA et al. (2010) Socioeconomic Status and the brain: mechanistic insights from human and animal research. Nat Rev Neurosci 11(9): 651 – 659.

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Fink, A. (2017). A Feminist Neuroethics of Mental Health. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/08/a-feminist-neuroethics-of-mental-health.html

The Politics of Elder Care, Social Care, and the “Dementia Tax”: A View from the United Kingdom

By Richard Ashcroft

Professor Richard Ashcroft, an AJOB Neuroscience Editorial Board member, teaches medical law and ethics at both the undergraduate and postgraduate level in the Department of Law at Queen Mary University of London.

The United Kingdom has recently gone through a General Election. The main reason the election was called by Prime Minister Theresa May was to secure a stronger mandate for the ruling Conservative Party, which was governing with a small overall majority of 19 seats over the Opposition parties. PM May’s argument was that in the negotiations with the other member states of the European Union over the UK’s exit from that Union (Brexit), an increased majority would give her a stronger bargaining position. As the election turned out, the electorate returned the Conservatives with fewer seats, and PM May had to form a minority administration, with a partial agreement to support the Conservative Party made with one of the smaller parties, the Democratic Unionist Party, which only contests seats in Northern Ireland. As a result PM May has a working majority, but one that is more fragile, rather than stronger.

Commentators have suggested a number of reasons for this outcome, but there seems to be general agreement that a turning point in the electoral campaign was the release of the election manifesto of the Conservative Party. While there are many reasons that might explain the downturn in support for PM May, one particular policy announced in the manifesto, deemed the “dementia tax,” attracted widespread criticism. 

UK population distribution.

Image courtesy of Wikimedia Commons.

The manifesto identified five key challenges for the UK, and policies to address these. One of the five is “The Ageing Society.” (The other four were: a need for a strong economy; Brexit and a changing world; enduring social divisions; and fast-changing technology). The ageing society is addressed in chapter 4 of the manifesto, which notes that “our system of elderly care is not working for the hundreds of thousands currently not getting the dignified and careful attention they deserve, nor for the people and organisations providing that care, nor is it sustainable for today’s younger people who will potentially face care costs themselves. It is not fair that the quality of care you receive and how much you pay for it depends in large part on where you live and whether you own your own home.” (p.64) 

This is a good summary, I think, of the consensus that has formed over the past few years about the nature of the financial problem facing social care in the UK. To understand the practical context for this, it is important to note that in the UK health and social care are separate systems. Whereas healthcare is financed (by and large) by the state centrally, mainly through publicly owned and managed providers (together referred to as the NHS), social care is, for the most part, delivered privately, with costs partly or wholly offset by funding through local government, subject to means testing and a variety of user charges. In some cases, a patient or service-user will get some care free, because it is delivered by and through the NHS; whereas another patient or service-user might get exactly the same type of care, but have to pay for it because it is delivered through the social care system. Some care is delivered in the patient or service-user’s own home (domiciliary care) and some is delivered through residential social care and some again is delivered in hospitals. While any changes in the finance or delivery or quality of health care quickly become headline news in the mass media, similar changes in social care rarely attract the same attention. A useful history of why we have this complex situation, which can fairly be described as a mess, is Nick Timmins’s The Five Giants: A Biography of the Welfare State (London: Harper Collins, 2001 [2nd edition]). 

Returning to finance, the Conservative manifesto says:

“Under the current system, care costs deplete an individual’s assets, including in some cases the family home, down to £23,250 or less. These costs can be catastrophic for those with modest or medium wealth. One purpose of long-term saving is to cover needs in old age; those who can should rightly contribute to their care from savings and accumulated wealth, rather than expecting current and future taxpayers to carry the cost on their behalf. Moreover, many older people have built considerable property assets due to rising property prices. Reconciling these competing pressures fairly and in a sustainable way has challenged many governments of the past.” (p.65) 

Image courtesy of Flickr user Myfuture.com.

Again, this is an apt diagnosis. Some elderly service-users are able to finance their care from income; typically these are the most wealthy, in particular those with high investment income or high occupational pensions. Others, whose income may be less, may be able to finance their care out of savings. A significant proportion, however, hold neither high paying occupational pensions nor hold significant savings, and their largest single capital asset is their homes. 

What the Conservative Party proposed was:

“First, we will align the future basis for means-testing for domiciliary care with that for residential care, so that people are looked after in the place that is best for them. This will mean that the value of the family home will be taken into account along with other assets and income, including value in the family home.   

“Second, to ensure this is fair, we will introduce a single capital floor, set at £100,000, more than four times the current means test threshold. This will ensure that, no matter how large the cost of care turns out to be, people will always retain at least £100,000 of their savings and assets, including value in the family home. 

“Third, we will extend the current freedom to defer payments for residential care to those receiving care at home, so no-one will have to sell their home in their lifetime to pay for care.” (p.65)

It was this financial proposal that received widespread criticism in much of the news media, from commentators on the political Right as well as in the Centre and on the Left. Many commentators focused on the shift from previous policy, which set a cap on how much an individual would have to pay before the state stepped on (as announced on p.65 in the Conservative Party’s manifesto for the 2015 General Election, following the recommendations of Sir Andrew Dilnot in his report to the then Conservative-Liberal Democrat coalition administration in July 2011). The proposal in the 2017 manifesto proposes a floor. The 2015 manifesto proposed that no one should pay more than a certain amount – undefined, but often quoted as being about £72 000. 

So if you held assets of say £500,000, you would be left, at death, with assets of about £428,000. Under the 2017 manifesto, you would pay out until you had £100,000 left. And while in the 2015 commitment your house would, under most circumstances, be ring-fenced from assessment, in 2017 it would not. This is a very significant difference, at least on paper. 

Image courtesy of Flickr user

American Advisors Group.

Other commentators highlighted the way bringing the home into the means test was unacceptable for other reasons: both because it is important to many families to be able to pass on the family home from parents to children, and because of the above noted point that the home is often the joint home of a couple or family, not simply the asset of the person needing care to be disposed of (even after their death in deferred settlement of care costs). 

The proposal quickly became labelled the “dementia tax.” This highlighted another politically contentious problem, and one of particular interest to the readers of this blog: crudely put – if you are dying over a period of some years of cancer, then all your care is funded by the NHS, with some services provided by charities which typically do not charge patients. Most palliative care is also free. 

Some domiciliary care may also be provided, which may attract charges, but family carers can get welfare benefits and other support. In other words, cancer is treated as an illness and is fully under the health service umbrella, provided free at the point of use and funded through general taxation (and to some extent through charitable giving). On the other hand, if you are dying of Alzheimer’s or Parkinson’s disease, although your medical care will be supervised through the NHS, in general you are treated as needing social care, and this you have to pay for up to the point where you pass through the means-test threshold. 

Thus, disorders such as Parkinson’s and the dementias are not treated as health conditions but as social needs. 

Image courtesy of Wikimedia Commons.

And moreover, in the current state of medical knowledge, neither is preventable or even predictable; thus, there is no obvious reason why this distinction should be drawn where it is, or why one should attract high costs payable by the patient and his or her family and the other does not. 

In the aftermath of the highly critical reception of this proposal, PM May was reported to have announced that there would, after all, be a limit on how much people were going to have to pay. 

After the election, when the new administration was finally formed and its legislative platform was announced to Parliament in the traditional Queen’s Speech, the social care had been dropped. 

The other main parties had also considered social care in their manifestos. The Labour Party proposed to “lay the foundations for a National Care Service” (p.72), although much of the detail on financing was to be worked out through “consensus on a cross-party basis about how it should be funded.” The Liberal Democratic Party also announced general reforms, in particular the implementation of a cap on social care costs to patients, but focussing mainly on structural reforms, and without much detail on financing. And the Scottish National Party, which went into the General Election as the third largest party in Parliament, committed to continuing “free personal care for older people” (which as the governing party in the Scottish Parliament it is able to control following Scottish devolution in 1999) but made no commitment on residential care, (p.5). 

What can we learn about social care from this short tour through our recent general election? First of all, we learn that it is a high risk political issue, which three of the four main parties handled, as it were, with asbestos gloves, and the fourth party, which entered the election expecting to win handsomely, decided to make a central part of its platform. It then discovered that unless carefully thought through and consulted upon, social care could be a political issue which, far from being a minority issue, could turn an election campaign sour very quickly. No one had predicted, when the election was called, that social care would turn out to be one of the key defining issues. What should perhaps have alerted politicians to its importance is the well known findings that older people are more likely to vote and that older people are more likely to vote Conservative. These data from polling company YouGov give the picture. 

Image courtesy of Wikimedia Commons.

Social care financing is a complex issue, and the technical details are not generally well known. Policy debates about social care financing rarely get into the mainstream media. And, to be frank, even philosophers and economists find debates about intergenerational equity… difficult. That said, it is not immediately obvious that older voters are unreasonable in their demands or would necessarily disagree with the solidarity argument laid out in the Conservative manifesto. Their resistance to the specific proposals would likely involve a complex narrative involving the emotional and family importance of their homes, their fear of dementia, concern with the quality of social care provision, concern for their legacy to their children, and so on— which does not pick out a clear policy path to follow. 

And yet, as the Conservative manifesto makes clear, “the ageing society” is one of the defining political and ethical challenges of our era. 

The status quo is riddled with incoherence and injustice, which everyone acknowledges, and to this extent the Conservative Party deserves a degree of non-partisan applause for seeking, however unsuccessfully, to lay this before the electorate. 

A concluding challenge, then, for ethicists: this episode should make it strikingly clear that we should be playing our part to clarify the social and health policy challenges of ageing, and perhaps especially those challenges associated with the currently hardly treatable, unpreventable and unpredictable diseases of brain and mind, and to work with economists and public policy scholars to devise ethically sound options. Inevitably there will be political debate about which path to go down. But political debate is imperative here; political silence cannot be allowed to resume.

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Ashcroft, R. (2017). The Politics of Elder Care, Social Care, and the “Dementia Tax”: A View from the United Kingdom. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/08/the-politics-of-elder-care-social-care.html

The Neuroethics Blog Series on Black Mirror: The Entire History of You

By Somnath Das

Somnath Das recently graduated from Emory University where he majored in Neuroscience and Chemistry. He will be attending medical school at Thomas Jefferson University starting in the Fall of 2017. The son of two Indian immigrants, he developed an interest in healthcare after observing how his extended family sought help from India's healthcare system to seek relief from chronic illnesses. Somnath’s interest in medicine currently focuses on understanding the social construction of health and healthcare delivery. Studying Neuroethics has allowed him to combine his love for neuroscience, his interest in medicine, and his wish to help others into a multidisciplinary, rewarding practice of scholarship which to this day enriches how he views both developing neurotechnologies and the world around him. 

Humans in the 21st century have an intimate relationship with technology. Much of our lives are spent being informed and entertained by screens. Technological advancements in science and medicine have helped and healed in ways we previously couldn’t dream of. But what unanticipated consequences may be lurking behind our rapid expansion into new technological territory? This question is continually being explored in the British sci-fi TV series Black Mirror, which provides a glimpse into the not-so-distant future and warns us to be mindful of how we treat our technology and how it can affect us in return. This piece is part of a series of posts that will discuss ethical issues surrounding neuro-technologies featured in the show and will compare how similar technologies are impacting us in the real world. 

*SPOILER ALERT* - The following contains plot spoilers for the Netflix television series Black Mirror.

Image courtesy of Flickr user

Kalvicio de las Nieves.

As the population ages, diseases of memory impairment such as Alzheimer’s disease have become of increasing concern across the globe. In fact, for adults over 55, Alzheimer’s is the number one feared disease (more than cancer). According to the Alzheimer’s association, deaths due to heart disease have declined by 14%, whereas deaths arising from Alzheimer’s disease-related causes have risen by 89%. Memory enhancement has also been explored by researchers as a way of enhancing – or dampening – functionally normal memory. Various techniques aimed at enhancing memory have explored the possibility of modulating memory’s various components, ranging from enhancing molecular processes to altering systemic neurotransmission (Stern & Alberini 2013; Suthana et al. 2012).

What if we could use a device that allows us to record our memories in real-time? Black Mirror explores this possibility in an episode entitled, “The Entire History of You,” by proposing a future where every person is implanted with a device behind their ears, called the “grain,” which performs this function. The grain records the user’s life in real time and allows the user to replay and modify past memories. The grain, in essence, serves as a form of memory prosthesis.

Plot Summary and Technology Used

Image courtesy of Wikimedia Commons.

“The Entire History of You” begins with Liam, who uses his grain to re-watch a recent interview

repeatedly, thinking he did not perform up to expectations. He uses the grain’s functionality to zoom in on the interviewer’s body language, scrutinizing their responses and subtly hinting how the device encourages paranoid tendencies. At a dinner party, he notices his wife, Ffion, talking to a man, Jonas, that he doesn’t recognize, thus arousing Liam’s suspicions. When the couple returns home, Ffion admits to Liam that she had a relationship with Jonas and that she had lied about the time they spent together. This causes a fight between the couple, and even though they apologize and make-up, Liam’s suspicions continue to linger. He eventually goes downstairs and, under the influence of alcohol, uses his grain to re-watch his wife’s conversations with Jonas at the dinner party. In a fit of rage, Liam drives to Jonas’ house, threatening to cut out Jonas’ grain if he doesn’t delete the memories of his prior relationship with Ffion. The next morning, Liam replays the incident, zooming in on the list of memories Jonas deleted. He noticed that there was footage of Jonas and Ffion having sex that was taken 18 months ago, around the time their daughter, Jodie, was conceived. After confronting Ffion about the footage, it suddenly becomes unclear as to who was the father of Jodie. The episode ends with Liam walking around his house, replaying his memories with Jodie. He then goes to the bathroom and removes the grain using a razor blade.

Image courtesy of Wikimedia Commons.

Everybody is implanted with the grain from birth, so the technology is not considered a form of enhancement (in fact, removing the grain may be so). One of the guests revealed that she had her grain forcibly removed, and that she prefers to remain grain-free. With the grain, the user can record memories in ultra high-definition (evidenced by the fact that Liam was able to zoom in on previous memories), replay them an unlimited number times, and even project their memories to be seen by others. The user can also selectively dampen their memories by deleting either segments or entire memories. What the show leaves unclear, likely on purpose, is how this device interacts with or changes the brain. For example, would Jonas be able to remember his time with Ffion, or at least their emotional connection, despite deleting all of their episodic memories on the grain? And, do these devices enhance or ultimately worsen the brain’s capacity for memory because of decreased reliance

– or decreased dependence – on our own biology?

The Current State of Technology: How close are we to memory BCIs, and how would they work?

While Black Mirror proposes a device that is similar to a camera with video-editing software that interacts with our brain and replaces declarative memory, scientists are currently exploring the use of brain-computer interfaces (BCIs) to modulate memory in a slightly different manner. The BCIs currently being explored use recorded neural activity to improve and optimize the brain’s own capacity to encode and store memories.

This year has seen a remarkable increase of interest in BCIs and memory modulation from a variety of stakeholders. The U.S. Defense Research Projects Agency (DARPA) aims to begin implanting memory prosthetics for veterans with traumatic brain injury in 2018. Kernel, a startup company, also recently revealed its aim to develop a BCI that aids those with memory problems. The company’s goals are largely clinical, aiming to help people suffering from traumatic brain injury or dementias including Alzheimer’s disease. This memory-prosthetic device would be implanted into the hippocampus. In a similar vein to deep brain stimulation (DBS) used to treat Parkinson’s disease, the device will aim to take the brain’s electrical signals and augment them to improve memory. In the context of Kernel’s device, the BCI would supplant the function of the hippocampus, encoding the process of learning into electrical signals and integrating these signals into the cortex.

Logo of the transhumanist movement.

Image courtesy of Wikimedia Commons.

Kernel’s project is largely based off of the research of USC biomedical engineer and neuroscientist Theodore Berger. Berger’s early research focused on Pavlovian conditioning in rabbits; he discovered that as the rabbits were learning to associate a tone with a puff of air – and subsequently blink when the tone was played – one region of their brains displayed a consistent and reliable pattern of electrical activity, indicating learning. His research currently focuses on recording neural substrates of memory and mathematically modeling them for use in memory prosthetic devices – a goal that is part of his Transhumanist aim to eventually create human cyborgs free of disability. He has published data that demonstrates a neuroprosthetic device’s ability to improve non-human primate hippocampal CA1-CA3 firing – a critical circuit in memory formation in the hippocampus (Hampson et al. 2013).

A study by Burke et al. (2013) demonstrated a potential mechanism of how a BCI may improve free recall in humans. Burke’s group recorded electrical activity in epileptic patients during a recall task (these patients already had electrodes implanted in their brain for therapeutic purposes). The intent of their BCI was to record patterns of pre-stimulus hippocampal activity to determine the optimal time to present images to recall later. When asked to recall, BCI patients were presented with words in accordance with the optimal electrical patterns as determined by EEG recording and the BCI, and it was found that the BCI improved the recall of these patients when compared to controls in more sessions than was expected by chance.

Other researchers are devoting increased attention to understanding how our brains encode visual sensory data. In 2011, Jack Gallant and his team successfully developed a model that allowed them to visualize how the brain – specifically the visual cortex – encodes data from natural movies (movies about nature). What remains to be seen, however, is whether Gallant’s et al.’s model is accurate for higher visual areas that process more complex aspects of vision. BCIs in the future could focus on using the findings of Gallant’s team in order to collect and store visual memories, which would hover closer to the technology used in Black Mirror.

Ethical Considerations: What Black Mirror gets right and what it misses

Despite the push by Kernel and others to create memory prosthetics, there remains to be a clear consensus on whether researchers possess enough knowledge of the brain’s memory encoding processes to make such devices. To achieve his own dream of making the devices available to the general public, Berger will have to test the devices on a variety of clinical populations outside of patients with epilepsy and the elderly. Additionally, Berger’s approach involves the codification of memory consolidation in a controlled setting. It could be that, for example, researchers fail to capture the true range of human memory consolidation in their codification, calling into question the ability of computers to replicate a complex process that is influenced by a host of other factors such as emotions and a multitude of physical sensations.

Image courtesy of Wikimedia Commons.

Privacy is also a significant concern. The technology in Black Mirror integrates smoothly and seamlessly with the user’s perception of the world, able to record and replay memories in real-time. The user can replay memories either “in their minds,” or project them on a television screen. The science behind creating a wearable recording technology that is similar to Black Mirror’s is within reach; yet, early versions of wearable recording technology are facing widespread consumer backlash. Google Glass, a pair of “smart glasses” that could take photos on command, faced remarkable negative criticism due to privacy concerns about the data collected by Google. A 2016 study by Takabi, Bhalotiya, and Alohaly found that the many third-party developers for current BCIs used in a wide variety of contexts such as gaming possess virtually unrestricted access to raw EEG data from users. These developers additionally possess a fairly strong locus of control over the stimuli shown to the users, leaving the question of how the users’ data will be used in context. The authors point out that while raw EEG data does have strong implications for clinical research, this data can also be used or sold to other third-parties and used for malicious intents. Additionally, the authors note that the ability of computational to trace brain signals back to users is growing, and therefore even if data is made anonymous, these protections may not be enough. Therefore, as BCIs are used for increasingly personal and therapeutic contexts (such as improving memory), computer scientists, neuroscientists, policymakers, and clinicians must work together to develop stronger protections for both user and patient neural data.

Image courtesy of Armed with Science.

Finally, as BCIs become more available as a treatment option, there will need to be a clear consensus communicated to physicians as to what specific aspects of memory these devices could enhance, and how these aspects of memory are modulated with respect to human memory’s various psychological and anatomical components. As with technologies still in clinical trials involving stimulation of the brain, potential conflation of therapeutic and experimental intents will need to be addressed in the clinic prior to consent and implantation. Bioethicist James Giordano worries that these devices could blur the links between emotion and memory, further threatening the identity of vulnerable patients in a diseased or disabled state. Black Mirror hints that even if these devices were to enhance declarative memory, they could worsen paranoid tendencies and traumatic associations with various memories. In their qualitative study of neurosurgical patients, Lipsman, Zener, & Bernstein (2013) observed that while patients undergoing invasive neurosurgery consider threats to identity as being outweighed by life-threatening conditions, they have considerable doubts about cosmetic and enhancement neurosurgery. Is dementia considered “life-threatening” enough for patients to accept potentially risky BCIs? And how about these devices within enhancement contexts?

Conclusions

The approach and philosophy adopted by Black Mirror of a camera for everybody’s brain may be reflected in the minds and aspirations of those in Silicon Valley; yet, scientists and neuroscientists are currently devoting increased attention on improving the state of internal memory encoding contained within our own biology. In contrast to how memory prosthesis is presented in Black Mirror, scientists and clinicians are investigating these devices for largely therapeutic purposes. Furthermore, the public perception of technologies that seek to record and digitally store memories (such as Google Glass) is that of significant concern. That being said, the safety and science behind memory prosthetic implantation still remains to be thoroughly investigated. Can all aspects of memory be fully coded into a BCI? How do we communicate the realities of memory prosthesis effectively to patients with disabilities and their families? Finally, how do we effectively protect patient neural data from being sold to third-parties or from being identified by others? While Black Mirror is a show meant for entertainment and available neurotechnologies are far from anything close to the “grain” device, science fiction also provides an opportunity for us to consider our current realities and potential futures.

References

Burke, J. F., Merkow, M. B., Jacobs, J., Kahana, M. J., & Zaghloul, K. A. (2014). Brain computer interface to enhance episodic memory in human participants. Frontiers in Human Neuroscience, 8, 1055. http://doi.org/10.3389/fnhum.2014.01055

Farah, M. J. (2015). An ethics toolbox for neurotechnology. Neuron, 86(1), 34-37. doi:10.1016/j.neuron.2015.03.038

Hampson, R. E., Song, D., Opris, I., Santos, L. M., Shin, D. C., Gerhardt, G. A., … Deadwyler, S. A. (2013). Facilitation of Memory Encoding in Primate Hippocampus by a Neuroprosthesis that Promotes Task Specific Neural Firing. Journal of Neural Engineering, 10(6), 066013. http://doi.org/10.1088/1741-2560/10/6/066013

Lipsman, N., Zener, R., & Bernstein, M. (2009). Personal identity, enhancement and neurosurgery: a qualitative study in applied neuroethics. Bioethics, 23(6), 375-383. doi:10.1111/j.1467-8519.2009.01729.x 

Ramesh, Sunidhi. (2017). The [Sea] Monster Inside Me. The Neuroethics Blog. Retrieved on July 11, 2017, from http://www.theneuroethicsblog.com/2017/05/the-sea-monster-inside-me.html

Sahu, S. (2017). M[Emory] Enhancement and its Implications. The Neuroethics Blog. Retrieved on July 11, 2017, from http://www.theneuroethicsblog.com/2017/03/memory-enhancement-and-its-implications.html

Stern, S. A., & Alberini, C. M. (2013). Mechanisms of memory enhancement. Wiley Interdisciplinary Reviews: Systems Biology and Medicine, 5(1), 37-53. DOI: 10.1002/wsbm.1196

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Das, S. (2017). The Neuroethics Blog Series on Black Mirror: The Entire History of You. The Neuroethics Blog. Retrieved on
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Criminal Law and Neuroscience: Hope or Hype?

By Stephen J. Morse

Stephen J. Morse, J.D., Ph.D., is a lawyer and a psychologist. He is Ferdinand Wakeman Hubbell Professor of Law, Professor of Psychology and Law in Psychiatry, and Associate Director of the Center for Neuroscience & Society at the University of Pennsylvania. Professor Morse is also a Diplomate in Forensic Psychology of the American Board of Professional Psychology. He has been working on the relation of neuroscience to law, ethics and social policy for over two decades, has written numerous articles and book chapters on these topics and has edited A Primer on Neuroscience and Criminal Law (Oxford University Press, 2013, with Adina Roskies). He was previously Co-Director of the MacArthur Foundation Law and Neuroscience Project and was a member of the MacArthur Foundation Law and Neuroscience Research Network. Professor Morse is a recipient of the American Academy of Forensic Psychology’s Distinguished Contribution Award, and a recipient of the American Psychiatric Association’s Isaac Ray Award for distinguished contributions to forensic psychiatry and the psychiatric aspects of jurisprudence. 

The discovery of functional magnetic resonance imaging (fMRI) in 1991, which permits non-invasive imaging of brain function, and the wide availability of scanners for research starting in about 2000 fueled claims that what we would learn about the brain and behavior would transform and perhaps revolutionize criminal law. Most commonly, many thought that traditional notions of criminal responsibility would be undermined for various reasons, such as demonstrating that people really cannot control themselves as well as we believe, or as indicating that more action was automatic, thoughtless and non-rational than we think. Most radically, the neuroexuberants argued that neuroscience shows that no one is really responsible because we are not agents; rather, we are victims of neuronal circumstances that mechanistically produce our epiphenomenal thoughts and our bodily movements. Similar claims were made when the genome was cracked. The age of cognitive, affective, and social neuroscience (behavioral neuroscience)—the neurosciences most relevant to law—is almost two decades old. What have we learned that is legally relevant and how has it transformed criminal law doctrine and practice?

Despite the astonishing advances in neuroscience, most of what we know is not legally relevant, has not transformed doctrine in the slightest and has had scant influence on practice except in death penalty proceedings. The reasons are conceptual, scientific, and practical. The first and most basic conceptual problem is that we have no idea how the brain enables the mind and action, although we know that it does. If your brain is dead, you have no mental states and do not act. The brain/mind/action connection is one of the hardest problems in science and neuroscience is not about to crack it anytime soon, if ever. 

Despite decades of research, the mind/action connection remains a black box.

Image courtesy of Pixabay.

The law’s culpability and responsibility criteria are all acts and mental states. Law is a thoroughly

folk psychological institution. In contrast, neuroscience, unlike psychology and psychiatry, is a completely mechanistic science. Neurons and even the connectome do not have aspirations, a sense of past, present and future, and intentions. These are mental states of human agents. Bridging the gap between folk psychology and mechanism is exceedingly difficult, especially as a result of some of the scientific and practical problems I will presently address. This problem cannot be avoided by claiming that the mind can be reduced to the brain. In addition to all the conceptual problems with the reductionist project, there has yet to be one successful demonstration of a reduction of mind and action to some allegedly more explanatory level of explanation. Failure to understand the relationship between neuroscience data and legal criteria has produced confused judicial decisions about whether proffered neuroscience evidence in criminal cases is genuinely relevant. 

A third conceptual problem is that psychology always precedes the behavioral neurosciences. Neuroscientists do not go on “fishing” expeditions. They have already behaviorally identified a behavior of interest, such as addiction, schizophrenia, or impulsivity, and now wish to investigate its neural correlates (and sometimes causes). But the behavior was already clear and the law is only concerned with behavior. The question, then, is what the neuroscience adds. If diffusion tensor imaging (DTI) of the adolescent brain indicated that it was indistinguishable from the adult brain, would we conclude that adolescents are behaviorally identical to adults? I submit we would think the neuroscience was not yet sophisticated enough to identify brain differences that surely exist because a fundamental axiom of materialism is that genuine behavioral differences must also be associated with brain differences. 

Image courtesy of Wikimedia Commons.

Another conceptual problem is the mistaken belief that neuroscience proves that determinism is true and the ongoing debate about the relation of determinism to free will and responsibility. No science can prove that determinism is true, however. It is simply a working hypothesis of most scientists and materialists more generally that could only be proven if would could get outside the universe and look in. Even neuroscientists and lawyers can’t do that. Moreover, the dominant view in the philosophy of responsibility is compatibilism, which holds that normal human beings have enough freedom to be held robustly responsible even if determinism is true. Finally, free will is not a criterion of any criminal law doctrine and on a compatibilist reading of the determinism debate, it is not even foundational. 

A final conceptual problem is that most of the neuroscience research is normatively inert. It may tell us, for example, that a certain region of interest (ROI) in the brain is activated beyond its base rate when the subject engages in a legally relevant task, such as deciding how much punishment to impose. Nevertheless, such correlational or even causal knowledge does not answer the normative question of how much punishment should be imposed. 

The scientific and practical problems that beset obtaining legally-relevant neuroscience blend together. There are few if any funding sources for specifically legally-relevant research that seeks to help answer a normatively important legal question. Most research is more basic and can only be inferentially relevant at best. This is a practical limit on the legally-relevant knowledge the science can offer. 

The “new” neuroscience using non-invasive imaging is very young and is working on some of the hardest problems in all science. It is no surprise that the knowledge base is still insecure despite the many major advances. There are many scientific problems that beset the science for legal purposes, but I will highlight just a few. Imaging is expensive, so the number of subjects in most studies is still very small, thus limiting their power. The subjects tend to be relatively healthy college students who are not a representative sample of the population at large and most certainly not representative of the population of violent criminals that are the main focus of attention. Numerous methodological artifacts are constantly being discovered, and reviews by eminent methodologists have estimated that as many as fifty percent of published studies are wrong or not reproducible. Perhaps most importantly, virtually none of the studies that proponents use to support legal arguments has been replicated. It is now well-known that there is a “replication crisis” in psychology and medicine, and neuroscience is no exception. Law, like medicine, can have a profound impact on individuals and society. No case should be decided or legal policy adopted based on insecure scientific knowledge. Too much is at stake. Until the knowledge base is more established, the real relevance of neuroscience to law, as opposed to the rhetorical relevance of startling images, must be modest. 

Image courtesy of Flickr user SalFalko.

In 2013, an eminent neuroscientist, Bill Newsome of Stanford, and I published a review of the potentially legally-relevant neuroscience to all the doctrines of criminal law. We concluded that with the exception of a few well-characterized medically-recognized conditions, such as epilepsy, which are the old neurology, the new neuroscience had virtually nothing to contribute to the adjudication of criminal law or criminal justice policy. Nothing has changed since then. 

Despite the generally negative evaluation expressed in this blog, I end on a note of hope.

Neuroscience may in the future help the criminal law become more just and efficient in modest ways. The validity of some doctrines may be confirmed or disconfirmed. For example, whether neuroscience can help understand whether there is an independent basis for the ability to control oneself may be very helpful. Most optimistically, the criminal law’s use of predictions for bail, diversion, probation, and parole may be enhanced by the use of neuro-variables. At present, there are some proof of concept studies that demonstrate that adding a neuro-variable to a prediction may enhance accuracy. They are not ready for prime time, but they are a positive step. Many civil libertarians fear we may become too accurate. I doubt it. But if we have already decided that predictions are normatively acceptable in the criminal justice process, as we have, what is the possible rational argument for predicting less rather than more accurately? 

In short, the present contribution of neuroscience to criminal law is more hype than hope, but in the future neuroscience may make modest contributions. For now, the neuroexuberants who suffer from Brain Overclaim Syndrome (BOS), should seek Cognitive Jurotherapy (CJ), a proven safe, effective, and non-invasive therapy. 

Suggested readings

Morse, Stephen J., and William T. Newsome. "Criminal Responsibility, Criminal Competence, and Prediction of Criminal Behavior." In A Primer on Criminal Law and Neuroscience: A contribution of the Law and Neuroscience Project, supported by the MacArthur Foundation, by Morse, Stephen J., and Adina L. Roskies, eds., edited by Stephen J. Morse, and Adina L. Roskies. Oxford University Press, 2013. Oxford Scholarship Online, 2013. doi: 10.1093/acprof:oso/9780199859177.003.0006.

Morse, Stephen J. "Lost in Translation? An Essay on Law and Neuroscience." In Law and Neuroscience: Current Legal Issues Volume 13, by Freeman, Michael, ed., edited by Michael Freeman. Oxford: Oxford University Press, 2011. Oxford Scholarship Online, 2011. doi: 10.1093/acprof:oso/9780199599844.003.0028. 

Morse, Stephen J., "Actions Speak Louder than Images: The Use of Neuroscientific Evidence in Criminal Cases." (2016). Faculty Scholarship. Paper 1648.

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Morse, S. (2017). Criminal Law and Neuroscience: Hope or Hype? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2017/07/criminal-law-and-neuroscience-hope-or.html