Ethical Concerns Surrounding Psychiatric Treatments: Do Academics Agree with the Public?

By Laura Y. Cabrera, Rachel McKenzie, Robyn Bluhm

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Treatments for psychiatric disorders raise unique ethical issues because they aim to change behaviors, beliefs, and affective responses that are central to an individual’s sense of who they are. For example, interventions for depression aim to change feelings of guilt and worthlessness (as well as depressed mood), while treatments for obsessive-compulsive disorder try to diminish both problematic obsessive beliefs and compulsive behaviors. In addition to the specific mental states that are the target of intervention, these treatments can also affect non-pathological values, beliefs, and affective responses. The bioethics and neuroethics communities have been discussing the ethical concerns that these changes pose for individual identity [1,2], personality [3,4], responsibility [5], autonomy [6,7], authenticity [8], and agency [9,10]. 

What we did

Pharmacological interventions such as antidepressants, antipsychotics, and stimulants, and neurosurgical psychiatric interventions such as ablative surgeries and deep brain stimulation, can be regarded as more “direct” in their mechanisms of action (compared to psychotherapy or other behavioral therapies) and therefore raise greater concern about their effects on the patient. We set out to compare ethical issues brought up by these two types of psychiatric interventions. Given the recent increase in research on neurosurgical interventions in psychiatry (as well as the historical precedents), it is really important to compare discussions of these therapies with those of pharmacological interventions. In our study, we were interested in comparing two key stakeholders around these interventions: the academic community and the public. The former because the academic discussion around these topics has a long history, and because academics can influence clinical guidelines and

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proposed recommendations that play a role in whether or not to adopt a particular intervention, as well as identifying the type of safeguards that might be warranted. The latter group we see as important because the public has, and should have, influence in shaping the future use of pharmacological and neurosurgical interventions. For example, think of the impact that the public’s voice has had in the negative perceptions around electroconvulsive therapy. There can be a disconnect between these two groups, however, when discussing the relevancy, legitimacy, and significance of these certain issues [9]. 

We compared ethical concerns raised regarding neurosurgical and pharmacological interventions and examined how these ethical issues are discussed both in the academic community and among the public. To gauge academic perspectives, we analyzed the medical and bioethics literature discussing pharmacological and neurosurgical interventions in psychiatry together with some discussion of ethical concerns. In the case of the public, we used online comments responding to articles covering interventions aimed at treating psychiatric disorders in major online American newspapers and magazines. Some examples of these comments are below.

Even though online comments can't provide a representative sample of public views, they are increasingly used by researchers to study public opinion on current issues [11]. The use of online comments has several advantages, including the possibility that, in a forum where people can comment anonymously (most people used pseudonyms or fake names), people may be more honest than they would be when interviewed by researchers. Yet, anonymity may foster commenters to write nonsense and politicize the conversation. While not all commenters provide rich and insightful comments, some are truly elaborated and reflect deep thinking on the issues at hand. 

Our analysis included perspectives related to various domains, including scientific and patient-related issues. Here, we focus on results related to philosophical and ethical concerns— specifically, six commonly discussed in the neuroethics literature: autonomy, authenticity, identity, enhancement, personal responsibility, and neurocentrism. 

What we found 

In a way, we were not surprised that the public and the academic groups have different concerns, or that different modalities shift the focus of attention to particular ethical and philosophical concerns. What surprised us the most was the predominance of the theme of “personal and social responsibility,” which aimed to capture whether or not a person with severe mental illness has a responsibility to do something about their disorder (such as try psychotherapy or any other intervention instead of or in addition to drugs/surgery). This theme also captures current social practices (e.g., stigma, blaming patients for their illnesses, and social conditions that might promote the prevalence of mental disorders) that might be responsible for exacerbating or failing to address mental problems, and was also one of the themes for which we do not find any statistically significant difference between the public and academic concerns. In the academic literature, personal responsibility was the most discussed concern for pharmacological interventions (32.6%), yet in the neurosurgery literature, it was issues of identity (62%). In the case of public concerns, personal and social responsibility was the most discussed concern in both types of interventions (pharma: 27.32%; neuro: 14.28%). 

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While we expected to find differences in the types of concerns raised, we did not expect to find such a difference in the frequency with which ethical and philosophical concerns are raised. Overall, philosophical issues were discussed less frequently in the public comments than the academic literature for both types of intervention (pharma: 40.55% vs. 66.27%; neuro: 27.32% vs. 82.35%). Perhaps we expected a public that was as keen to engage in these topics as we are; instead, we find a public that challenges assumptions about scientific validity and what counts as a disorder in addition to one that is willing to share personal anecdotes online. 

What we think it means 

These findings reveal similarities and discrepancies in how philosophical issues associated with these two types of psychiatric treatment are discussed both in professional circles and among the public. While the public might be less likely to use academic terms such as “authenticity” or “autonomy,” the few commenters that did bring up ethical concerns regarding the use of particular psychiatric interventions used terms such as “personality,” “true self,” or “his choice.” Thus, it is possible that there is a need to look more deeply into whether there are substantial differences on how these terms shape ethical concerns in these two groups. The differences found regarding the type of intervention also have important implications. For example, it is possible that academics see an important difference between the interventions. In the case of psychiatric neurosurgey, identity is a frequently raised ethical concern, but this is not true in the case of pharmaceuticals. The fact that contemporary forms of psychiatric neurosurgery are relatively new might explain why many members of the public commenting on neurosurgical interventions use more familiar interventions, such as pharmacological interventions, to try to understand and assess the issues involved. 

Conclusions 

The public as well as psychiatric patients should be able to access and understand the concerns of the scientific community in order to better discern the risks and benefits of treatments. There is certainly a growing acknowledgement that the public is not waiting to be educated by the experts (a.k.a. the deficit model of public engagement) but rather is a group of people who bring valuable perspectives and knowledge from which experts can learn and benefit. As such, it is essential that the scientific community adequately considers and addresses the public’s concerns and perspectives so as to provide future patients with effective care. 

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Dr. Laura Cabrera is Assistant Professor of Neuroethics at the Center for Ethics and Humanities in the Life Sciences. She is also Faculty Affiliate at the National Core for Neuroethics, University of British Columbia. Laura Cabrera's interests focus on the ethical and societal implications of neurotechnology, in particular when use for enhancement purposes as well as for treatments in psychiatry. She has been working on projects at the interface of conceptual and empirical methods, exploring the attitudes of professionals and the public toward pharmacological and brain stimulation interventions, as well as their normative implications. Her current work also focuses on the ethical and social implications of environmental changes for brain and mental health. She received a BSc in Electrical and Communication Engineering from the Instituto Tecnológico de Estudios Superiores de Monterrey (ITESM) in Mexico City, an MA in Applied Ethics from Linköping University in Sweden, and a PhD in Applied Ethics from Charles Sturt University in Australia. Her career goal is to pursue interdisciplinary neuroethics scholarship, provide active leadership, and train and mentor future leaders in the field. 

Rachel McKenzie is a fourth year undergraduate studying neuroscience at Michigan State University. She is interested in bioethics and science communication, and hopes to pursue a graduate degree and continue research in these areas after graduating in the spring.  

Robyn Bluhm is an Associate Professor in the Department of Philosophy and Lyman Briggs College at Michigan State University. Her research focuses on the relationship between epistemological and ethical issues in medicine and in neuroscience. She is the co-editor of Neurofeminism: Issues at the Intersection of Feminist Theory and Cognitive Science and of the International Journal of Feminist Approaches to Bioethics, and is the editor of Knowing and Acting in Medicine. 

 References



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Cabrera, L., McKenzie, R., Bluhm, R. (2018). Ethical Concerns Surrounding Psychiatric Treatments: Do Academics Agree with the Public? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2018/06/ethical-concerns-surrounding.html