How to be Opportunistic, Not Manipulative

By Nathan Ahlgrim

Opportunistic Research

Government data is often used to

answer key research questions.

Image courtesy of the U.S. Census Bureau

Opportunistic research has a long and prosperous history across the sciences. Research is classified as

opportunistic when researchers take advantage of a special situation. Quasi-experiments enabled by government programs, unique or isolated populations, and once-in-a-lifetime events can all trigger opportunistic research where no experiments were initially planned. Opportunistic research is not categorically problematic. If anything, it is categorically efficient. Many a study could not be ethically, financially, or logistically performed in the context of a randomized control trial.

Biomedical research is certainly not the only field that utilizes opportunistic research, but it does present additional ethical challenges. In contrast, many questions in social science research can only be ethically tested via opportunistic research, since funding agencies are wary of explicitly withholding resources from a ‘control’ population (Resch et al., 2014). We, as scientists, are indebted to patients who choose to donate their time and bodies to participate in scientific research while inside an inpatient ward; their volunteerism is the only way to perform some types of research.

Almost all information we have about human neurons comes from generous patients. For example, patients with treatment-resistant epilepsy can have tiny wires lowered into their brains, a technique known as intracranial microelectrode recording, enabling physicians to listen in on the neuronal chatter at a resolution normally restricted to animal models (Inman et al., 2017; Chiong et al., 2018). Seizures, caused by runaway excitation of the brain, are best detected by recording electrical signals throughout the brain. By having such fine spatial resolution inside a patient’s brain, surgeons can be incredibly precise in locating the site of the seizure and treating the patient. It’s what else those wires are used for that introduces thorny research ethics.

Image courtesy of Wikimedia Commons.

Those wires are already down there, so why not put them to even more use? Scientists dream of poring over the treasure trove of patients’ data. It’s a precious, and rare, resource. The elephant in the room, especially for practitioners of basic research, is that basic research is not expected to directly benefit the individual patient. Any scientific gain may help people in the years to come, but it will not affect that individual patient’s prognosis. Unlike studies trying to optimize deep brain stimulation (DBS) for treatment of Parkinson’s Disease (Müller and Christen, 2011) or depression (Dunn et al., 2011), basic research exists for the sake of science, not patient welfare. With fewer concrete benefits to the patient, the risk to benefit calculation becomes trickier.

Human neuroscience research like this is almost always expensive and demanding. That does not mean, however, that these experiments can be low priority. Our prodigious knowledge of the nervous system is only surpassed by our ignorance of it, and treatments for some of the most pressing health concerns of our time depend on research like this increasing our knowledge. Of course, such a strong motivation to innovate can blind scientists to the need to also protect their research participants, which is why specific ethical standards for opportunistic research need to be robust and ready.

Physician-led Opportunism

In the physician-patient relationship, the power dynamic lies in favor of the physician. Most physicians recognize and accept this dynamic when it comes to healthcare. Even so, many fail to appreciate that the power dynamic does not disappear when the conversation changes topic; the physician remains the physician even when she talks to her patient about non-therapeutic research.

Image courtesy of SVG Silh.

Non-medical invasive brain research, like that using intracranial recordings and brain stimulation in epilepsy patients, is admittedly a niche area. Since it has no immediate
implications for human health, it receives far less publicity and
public scrutiny than clinical trials or even promising treatments in
animal models (Fang and Casadevall, 2010). Although the purpose of basic
research is distinct, it can still benefit from the lessons learned on
the medical side. Clinical human neuroscience research shows that the ability to consent does not guarantee that the decision to consent is a voluntarily one (Swift, 2011). In the shadow of the physician-patient power dynamic, would-be participants can become situationally incapacitated even while retaining full mental capacity (Labuzetta et al., 2011). In effect, their position as a patient, the physician-patient relationship, and the overlap between medical and research practices can all render the patient incapable of freely giving informed consent. Although the mental state of the patient may be sound, many argue that they must be protected just like those who lack the mental capacity to consent on their own behalf. The fear is that any hint of the research influencing the medical care, or even the absence of addressing that interaction explicitly, can force the patient’s decision.

Of course, there is also a strong argument that consent, even if not fully voluntary, can be ethically valid. Even proponents of the so-called Autonomous Authorization criterion, under which consent is only valid when given intentionally, with full understanding, and without controlling influence (Faden and Beauchamp, 1986), often amend or bend those strict guidelines to make them practical (Miller and Wertheimer, 2011). Autonomous authorization can be eroded because of therapeutic misconception of research, when potential participants are influenced to enroll in a study due to confusion between research and medical treatment (Appelbaum et al., 1982). For instance, patients may enroll in a study testing a potential drug to treat Alzheimer’s Disease because they believe they will not be placed in the placebo group given their advanced condition. That is not how randomized control trials are designed. Patients’ misunderstanding inflates the benefits in their mind, which could sway their decision to participate. Yet the demand that all patients be fully knowledgeable before their consent is deemed valid may be too rigorous to be practical, and end up an unrealistic burden to place on researchers. Critics of the Autonomous Authorization model claim that responsibility for protecting patients resides in institutional safeguards (i.e. Institutional Review Boards [IRBs]), not the researchers themselves. With strong institutional standards in place, patients’ best interests can still be protected even if they give non-autonomous consent. That is, at least, the argument. How those safeguards are designed is the determining factor of their effectiveness.

How to Keep Consent Voluntary

We cannot pretend that the physician-patient power dynamic does not exist, or that every patient will become an expert in the research program they sign up for. Still, proactive steps on the institutional and personnel sides can protect participants and make sure they enroll because they want to, not because they feel they have to. The need for such protections is compounded by the specifics to invasive brain research, whose entire participant pool lives with a treatment-resistant brain disorder severe enough to merit invasive brain surgery. It is our unfortunate reality that stigma looms over people living with brain disorders, both external (from others) and internal (self-perception) (Corrigan et al., 2006). Stigma surrounding brain disorders weakens personal empowerment (Corrigan, 2002), tipping the balance of power even more strongly towards the physician and research team. The protections put in place for these participants must be comprehensive and robust to rebalance the relationship.

Teams performing invasive brain research have already made a series of recommendations to directly address the unique environment of non-medical invasive research using human patients (Chiong et al., 2018). Their recommendations are strong and worth implementing, but they fall short because of a common blind spot: they are still thinking like researchers, not patients.

Image courtesy of Pixabay user Catkin.

As a patient, you might be coerced to consent to any research protocol put in front of you out of fear that your medical treatment is dependent on it. You don’t even need to be a cynic who expects the worst out of your physician to fear this. After all, your physician will probably take more of an interest in you, and you’ll get more face time with her, if you sign up for her study. Yes, preferential treatment is wrong, but self-defense against improper treatment requires self-empowerment, something that is often degraded in these patients by the stigma following their brain disorder. To minimize potential coercion, physicians should at the very least complete the consent process as part of a team, alongside people not involved in the patient’s care. Of course, the coercion patients feel would be minimized if their physicians were completely absent during the consent process to minimize any implicit coercion, but such requirements are often impractical. Both medical and research personnel should also be required to explicitly state that medical care will not change for the better or worse regardless of research participation. These statements must be unequivocal, and repeated before, during, and after the consent process.

Even as I and others lay out a list of criteria for researchers to meet, it is important to stress that research teams cannot rely on a one-size-fits-all consent process. Individualization is especially necessary when researchers are working with a vulnerable population dependent on their care. The capacity to consent to medical interventions (which get the patient into the ward in the first place) does not imply the capacity to consent to research interventions. Even after patients do consent, their medical condition can fluctuate, as can their desire to participate. Just like with medical treatment, consent at the start of a project (no matter how ethically it was obtained) cannot be used to rubberstamp the entire study. Such protections are already given to psychiatric patients (Palmer et al., 2013), showing that the best consent is one that is renewed.

Institutional criteria can help bolster these practices, but relying too much on them is dangerous. After all, institutional priorities can bias the definition of “patient interests” and preferentially validate non-autonomous consent that aligns with institutional interests over the individual patient’s interest. Both personnel and institutional approaches fail to fully protect the patient/research participant dual role, which is why the two must work in tandem. It is far too easy for researchers to capitalize on a patient’s therapeutic misconception because it produces the desired outcome, even when the deception is unintentional.

Image courtesy of Wikipedia.

As a patient, being told your medical care is protected regardless of your research participation is not the same as believing it and trusting it to be true. Doubt may be unavoidable, and it is not preferable, but it should also not prevent the study from happening. Invasive brain research can only happen in specific and intensive situations, but it is absolutely necessary to the progress of neuroscience and medicine. Everything from epilepsy to Alzheimer’s Disease to autism is informed by and better treated because of invasive brain research.

Patients will be protected when physicians are trained to not display favoritism to their research participants and IRBs shape research protocols to fairly balance a participant’s risks and benefits. They will be protected even if they do not understand the research as well as the research team. Science does not have to stop until the public are all scientists. Scientists do, however, need to protect non-scientist interests, even when it feels like doing so gets in the way of progress. The discussion of the ethical challenges is not meant to detract that we, as a society, need this kind of research if we hope to continue improving overall health. The brain is boundlessly complex, and we do not understand it well enough to adequately treat those who need it. In short, our deep ignorance of the brain’s inner workings requires deep, and sometimes invasive, research.

________________

 Nathan Ahlgrim is a fifth year Ph.D. candidate in the Neuroscience
Program at Emory. In his research, he studies how different brain
regions interact to make certain memories stronger than others. He strengthens his own brain power by hiking through the north
Georgia mountains and reading highly technical science...fiction.









References



Appelbaum PS, Roth LH, Lidz C (1982) The therapeutic misconception: Informed consent in psychiatric research. International journal of law and psychiatry 5:319-329.



Chiong W, Leonard MK, Chang EF (2018) Neurosurgical patients as human research subjects: Ethical considerations in intracranial electrophysiology research. Neurosurgery 83:29-37.



Corrigan PW (2002) Empowerment and serious mental illness: Treatment partnerships and community opportunities. Psychiatric Quarterly 73:217-228.



Corrigan PW, Watson AC, Barr L (2006) The self–stigma of mental illness: Implications for self–esteem and self–efficacy. Journal of Social and Clinical Psychology 25:875-884.



Dunn LB, Holtzheimer PE, Hoop JG, Mayberg HS, Roberts LW, Appelbaum PS (2011) Ethical issues in deep brain stimulation research for treatment-resistant depression: Focus on risk and consent. AJOB Neuroscience 2:29-36.



Faden RR, Beauchamp TL (1986) A history and theory of informed consent: Oxford University Press.



Fang FC, Casadevall A (2010) Lost in translation—basic science in the era of translational research. Infection and Immunity 78:563-566.



Inman CS, Manns JR, Bijanki KR, Bass DI, Hamann S, Drane DL, Fasano RE, Kovach CK, Gross RE, Willie JT (2017) Direct electrical stimulation of the amygdala enhances declarative memory in humans. Proceedings of the National Academy of Sciences.



Labuzetta JN, Burnstein R, Pickard J (2011) Ethical issues in consenting vulnerable patients for neuroscience research. Journal of Psychopharmacology 25:205-210.



Miller FG, Wertheimer A (2011) The fair transaction model of informed consent: An alternative to autonomous authorization. Kennedy Institute of Ethics Journal 21:201-218.



Müller S, Christen M (2011) Deep brain stimulation in parkinsonian patients—ethical evaluation of cognitive, affective, and behavioral sequelae. AJOB Neuroscience 2:3-13.



Palmer BW, Savla GN, Roesch SC, Jeste DV (2013) Changes in capacity to consent over time in patients involved in psychiatric research. The British Journal of Psychiatry 202:454-458.



Resch A, Berk J, Akers L (2014) Recognizing and conducting opportunistic experiments in education: A guide for policymakers and researchers In. Washington, D.C.: U.S. Department of Education.



Swift T (2011) Desperation may affect autonomy but not informed consent. AJOB Neuroscience 2:45-46.



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Ahlgrim, N. (2018). How to be Opportunistic, Not Manipulative. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2018/10/how-to-be-opportunistic-not-manipulative.html

International Neuroethics Society Annual Meeting Summary: Ethics of Neuroscience and Neurotechnology

By Ian Stevens

Ian is a 4th year undergraduate student at Northern Arizona University. He is majoring in Biomedical Sciences with minors in Psychological Sciences and Philosophy to pursue interdisciplinary research on how medicine, neuroscience, and philosophy connect. 



At the 2017 International Neuroethics Society Annual Meeting, an array of neuroscientists, physicians, philosophers, and lawyers gathered to discuss the ethical implications of neuroscientific research in addiction, neurotechnology, and the judicial system. A panel consisting of Dr. Frederic Gilbert with the University of Washington, Dr. Merlin Bittlinger, with the Universitätsmedizin Berlin – Charité, and Dr. Anna Wexler with the University of Pennsylvania presented their research on the ethics of neurotechnologies.

Dr. Gilbert discussed the cultivation and development of neurotechnologies that use artificial intelligence (AI) to operate brain-computer interfaces (BCI), such as the implanted seizure advisory system, which is implanted invasively into the brain for the treatment of drug-resistant epilepsy (1). He provided three main reasons for the ethical examination of such developing neurotechnologies. The first is that these devices could provide “neuro-signatures” that could aid in the detection of addiction and sexual urges. These issues could challenge our notions of privacy and autonomy, concerns that are being explored with other technologies (2, 3). Secondly these devices, as other similar invasive neurotechnologies, have been shown to cause or be associated with personality changes and because of this we need to understand how these technologies might affect a patient’s notion of self and identity (4). It seems concerning to enter a treatment as a certain person but leave as another. How the risks and benefits of treatment are balanced when a patient prior to surgery might not be the same afterwards challenges conventional standards of risk and benefit. Finally, the field of AI with BCIs is a very ambiguous one with the pace of developing predictive brain implants exceeding our understandings of how they will affect us (5).

Expanding on his second justification, Dr. Gilbert discussed his research on ways these artificially intelligent devices can alter subjects’ perception of themselves. He used qualitative data from interviews to assess the concern that BCIs alter personalities and shared two stories of a 52-year-old woman receiving an AI BCI for epilepsy and a younger female student also being treated for epilepsy with an AI BCI (6). The 52-year-old woman stated that, because of the implanted AI device, she felt like she could do anything, and nothing could stop her (AI BCI induced postoperative distorted perception of capacities).

An open brain-computer interface (BCI) board.

(Image courtesy of Wikimedia.)

This contrasted with the student who experienced postoperative symptoms of depression because she felt the AI device forced her to confront the fact that she was epileptic (AI BCI induced drastic rupture in identity leading to iatrogenic harms). These dialogues have lead Dr. Gilbert to argue for a distinction between restorative and deteriorative personality changes associated with BCIs (what he calls “self-estrangement”) (7).



This distinction is initially helpful for two possible reasons. One, it assists in confirming that a patient’s sense of identity can change in reference to the AI BCI they are treated with, but also that there are certain kinds of patients who are incompatible with being treated with BCIs. Like pharmacological treatments for mental health, some patients might not benefit from the deleterious identify changes associated with their AI BCI treatment. So, in conclusion, Dr. Gilbert advised that those who are not accepting of their neurologic disease should not undergo AI BCI treatment out of concern for the device having a destructive change in their core personality.

Dr. Bittlinger, whose current work focuses on the ethical, legal, and social aspects of psychiatric neurosurgery, presented his research on the ethical evaluation of innovative research involving unknown risk by using the example of deep brain stimulation (DBS) in Alzheimer’s Disease (AD). Dr. Bittlinger emphasized how much of a global burden AD is, with no cure within sight. With only a few drugs available for treating the symptoms of AD, there is an obvious need for innovative research. He said that using DBS as an innovative, or currently unconventional, treatment should be examined ethically before we proceed down the road to other treatment options. To support this, Dr. Bittlinger quoted the Declaration of Helsinki (8) and its sentiments on the need for the patients to be autonomous beings and the importance of consent in research. The notion that the risks undertaken by patients should be low and minimal is not addressed, however, and DBS is in the highest risk class of treatments being explored for AD because of its invasive nature. The Declaration of Helsinki points to this importance, stating “individuals must not be included in a research study that has no likelihood of benefit for them unless it is intended to promote the health of the group represented by the potential subject, the research cannot instead be performed with persons capable of providing informed consent, and the research entails only minimal risk and minimal burden” (9). While all treatments in clinical trials strive for this, the innovative nature of DBS for AD possess large risks for unknown benefits. While AD can be debilitating to the patient, the risk associated with invasive implantation may be too great. Because of this and the fact that clinical trials include possibly un-autonomous decision-makers (the Alzheimer’s populous), Dr. Bittlinger stressed the need for further evidence of DBS efficacy in the long-term.

Image courtesy of Pixabay.

Dr. Bittlinger’s take home message was that “neuroethicists should encourage researchers to see methodological rigor not only as a liability but as an asset.” He is advocating for a form of methodological beneficence. While trials might normally look to cause minimal maleficence, questioning the implicit structure of research to be ethical could provide benefits in the realms of research with the highest risk. After an extensive literature review, Dr. Bittlinger made the important distinction between studies with no unknown risk compared to those with no knowledge of unknown risks (10). This uncertainty of the unknowns is the basis for Dr. Bittlinger’s question of exactly how much pre-clinical data is required to justify clinical interventions with DBS for Alzheimer’s disease. In line with this methodological beneficence and using probability models, Dr. Bittlinger finished off his talk when he stressed the need for neuroscientists to prioritize confirmatory clinical trials over exploratory ones in early stages of research.

Finally, Dr. Wexler presented on the use of brain stimulation in a variety of health and wellness clinics around the United States. Her work focused on the use of tDCS (transcranial direct current stimulation) and how the current studies on the subject have suggested its effectiveness in treating depression, chronic pain, and cognitive enhancement (though there is still debate in the literature about the efficacy of tDCS). She also noted that there is a larger presence of tDCS use in the DIY (Do It Yourself) community, where people fashion their own devices with batteries and sponges; however, it has been more common for tDCS products to be obtained as consumer products (11). Her fascination with the field came from the fact that two groups use these devices: researchers (a very controlled setting) and average consumers (a very uncontrolled setting). However, what struck her was the fact that a third group of people, clinicians, were also using tDCS devices as a means of treatment for their patients (a semi-controlled setting). This semi-controlled setting was curious to Dr. Wexler since it was fraught with ethical concerns distinct from the well-known DIY concerns, and the possible off-label use of tDCS in such a setting.



The semi-structured environment of the clinic presents a clinical bioethical inquiry. How should these devices be regulated and how should they be understood as treatment options? Should they only be approved as a clinical treatment for disease, or perhaps as an off-label procedure to enhance?

Image courtesy of Pexels.

She defined an off-label use as a device or drug used for an intention other than it was approved and referenced using Trazadone, a drug used to treat depression, for alcohol dependency as an example (12). She then went on to discuss the open-ended semi-structured interviews she conducted with health care providers that offered tDCS services. Although the analyses are still underway, she shared some insights she has had so far; namely tDCS use has been tied to complementary and alternative medicine, the pricing of using such devices varies by provider, and the treatment focused on depression, anxiety, and ADD. Out of the practitioners, some thought that tDCS was FDA approved (when in fact it was not), and overall those using tDCS came from people possessing an MD, Ph.D. or no clinical background. Regardless of the legal distinctions between the regulation of the sale of tDCS devices or the use of them, the ethical questions she left us with are pressing ones. Should these devices be allowed to be used in clinics without supporting research?

The developing neurotechnologies are broad in their application, but there are common threads of ethical reflection that Dr. Gilbert, Dr. Bittlinger, and Dr. Wexler have highlighted. As with all new treatment options, our outlook as scientists, philosophers, lawyers, and ethicists should be critical, although not pessimistic. Neurotechnologies look to be great treatment options for many chronic neurological problems; however, the side-effects, and therefore the risk and benefit trade-offs are unknown. The “how” question of connecting the human brain with technology has been solved on some levels; however, what this connection ethically means still needs to be unraveled.

References

1. Mark J. Cook et al., “Prediction of Seizure Likelihood with a Long-Term, Implanted Seizure Advisory System in Patients with Drug-Resistant Epilepsy: A First-in-Man Study,” The Lancet. Neurology 12, no. 6 (June 2013): 563–71, https://doi.org/10.1016/S1474-4422(13)70075-9.

2. Tamara Denning, Yoky Matsuoka, and Tadayoshi Kohno, “Neurosecurity: Security and Privacy for Neural Devices,” Neurosurgical Focus 27, no. 1 (July 1, 2009): E7, https://doi.org/10.3171/2009.4.FOCUS0985.

3. Frederic Gilbert, “A Threat to Autonomy? The Intrusion of Predictive Brain Implants,” Ajob Neuroscience 6, no. 4 (October 2, 2015): 4–11, https://doi.org/10.1080/21507740.2015.1076087.

4. Frederic Gilbert et al., “I Miss Being Me: Phenomenological Effects of Deep Brain Stimulation,” AJOB Neuroscience 8, no. 2 (April 3, 2017): 96–109, https://doi.org/10.1080/21507740.2017.1320319.

5, 6, 7. Frederic. Gilbert et al., “Embodiment and Estrangement: Results from a First-in-Human ‘Intelligent BCI’ Trial,” Science and Engineering Ethics, 2017, https://doi.org/10.1007/s11948-017-0001-5.

8. “WMA - The World Medical Association-WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects,” accessed December 28, 2017, https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/.

9. “WMA - The World Medical Association-WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects.”

10. John Noel M. Viaña, Merlin Bittlinger, and Frederic Gilbert, “Ethical Considerations for Deep Brain Stimulation Trials in Patients with Early-Onset Alzheimer’s Disease,” Journal of Alzheimer’s Disease: JAD 58, no. 2 (2017): 289–301, https://doi.org/10.3233/JAD-161073.

11. Anna Wexler, “The Social Context of ‘Do-It-Yourself’ Brain Stimulation: Neurohackers, Biohackers, and Lifehackers,” Frontiers in Human Neuroscience 11 (2017), https://doi.org/10.3389/fnhum.2017.00224.

12. Letizia Bossini et al., “Off-Label Uses of Trazodone: A Review,” Expert Opinion on Pharmacotherapy 13, no. 12 (August 2012): 1707–17, https://doi.org/10.1517/14656566.2012.699523.

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Stevens, I. (2018). International Neuroethics Society Annual Meeting Summary: Ethics of Neuroscience and Neurotechnology. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2018/02/international-neuroethics-society_10.html

Can free will be modulated through electrical stimulation?

The will to persevere when many of life’s challenges are thrown at us is an ability that comes more naturally for some than for others. Additionally, even the most determined among us have days and times when moving forward through a challenging task just proves too difficult. The subjective nature of this experience can make it difficult to study, but recently researchers from Stanford University published a case study where electrical brain stimulation (EBS) to the anterior midcingulate cortex (aMCC) left two patients with the feeling that a challenge was approaching, but also that they could overcome it [1]. For the most recent journal club of the semester, Neuroscience graduate student and AJOB Neuroscience editorial intern Ryan Purcell led a discussion on the experimental procedure to stimulate what is referred to as the “the will to persevere” and the effect this technology may have if it were to become more mainstream in society.

"The location of the electrodes in P1 and P2 overlaid onto the standard emotional salience network derived from a group of normal human subjects." Parvizi et al.

It has long been known that the anterior cingulate cortex (ACC) and its midcingulate region (aMCC) are involved in emotions that rely on cognitive control, and recent research has shown that this brain network is possibly involved in complex emotions such as motivation and endurance [2,3]. In the case study discussed during journal club though, researchers went beyond an animal study and recorded a first-hand account of two patients becoming determined and motivated to overcome what they perceived as an oncoming challenge during EBS to the aMCC. The aMCC, located deep within the brain, is not typically implanted with electrodes for clinical reasons, but researchers were attempting to discover the origin of seizure activity in two patients with epilepsy by implanting intracranial electrodes in four different deep brain regions. Electrical currents at each of these regions were delivered and then based on patient feedback and physiological reports, researchers could localize the epileptic activity. It was determined that the patients were suffering from medial temporal epilepsy, but when electrical stimulation occurred at the aMCC, while no signs of seizures were observed, both patients did report similar and unique emotional states, along with specific physical symptoms. Patients physically experienced what was described as “shakiness,” hot flashes, and an increase in heart rate, but interestingly also psychologically felt a sense of foreboding regarding a challenge and the confidence that the challenge could be overcome. As seen in this supplemental video, patient 1 describes the experience as driving “towards a storm that’s on the other side, maybe a couple of miles away, and you've got to get across that hill.” Although this seems like a situation that would cause worry and anxiety, the same patient reported that the feeling was not really negative, but instead “it was more of a positive thing like…push harder, push harder, push harder to try and get through this.” These patient accounts suggest that researchers had tapped into the part of the brain responsible for motivation, endurance, and the will to persevere, and in doing so were able to elicit these feelings on command - far removed from any situation similar to stressful driving.



Researchers also realized that by stimulating the aMCC, the behavioral and emotional changes caused by EBS could potentially be due to functional changes that take place within a vast neuronal network connected to the aMCC. Using fMRI and functional connectivity analysis, researchers observed that EBS in the aMCC region of interest led to the activation of a network previously characterized as the emotional salience or cingulo-opercular network [4]. This suggests that the motivation, endurance, or the lack of these two emotions are most likely not alone regulated by a single brain region, the aMCC, but instead a complex, distributed network.



This paper presents the exciting and interesting idea that we could regulate motivation with stimulation to the brain, but really this is just a small case study with two patients. These findings may have been an unexpected result from trying to find the source of epilepsy, and may only occur in this experimental setting, perhaps even only in patients who have a history of epilepsy. The paper reads as if the researcher asking the questions of the patients was the same researcher conducting the stimulation trials, and as a result many of the questions are very biased and leading. After patient 1 has vividly compared his experience to driving in a storm, the researcher attempts to ask patient 2 about driving as well. To which patient 2 responds with laughter “I don’t get to drive.”



This is an interesting observation, but would need to be replicated on a larger scale with blind research practices put into place. However, since the aMCC is located deep within the brain and typically electrodes are not inserted for clinical reasons, it may prove difficult to conduct invasive procedures without a clinical agenda. In this case study, these patients were already unique in that they may have been very determined individuals even without external stimulation since they were undergoing invasive brain surgery for epilepsy most likely as a last resort. Having the power to increase motivation and/or determination could be used in a clinical setting for depression or chronic pain, and while it is only speculation regarding the personality traits of these two patients, a study that is open to participants without any diagnosed neurological disorders could provide more baseline activity for modulating the aMCC and its neuronal network. For this large study to take place though and to find interested participants, most likely the technology would need to advance with a noninvasive procedure.



While this type of technology would have obvious clinical benefits for treating depression and perhaps one day the ability to self-regulate our motivations at home, having the power to externally regulate free will begs certain questions. Should anyone be denied the chance to become a more productive, motivated version of themselves? Or, if this type of technology were considered acceptable, should anyone be forced to become a more determined, motivated citizen who does not experience weakness of will? If advances in neuroscience continue to address the questions of whether free will even exists at all, and then if we ever have the power to impose a standard of willpower that everyone should meet, this would have important implications for our legal and justice system. Two common theories for justifying punishment include the utilitarianism and the retributivism theory [5]. Simply put, utilitarianism is based on the idea that punishment is justified because it produces a situation in which the balance of good and evil (or happiness and unhappiness) is maximized [6]. Punishment helps to reduce crimes, which promotes a society where good prevails over evil. For example, punishment in the form of imprisonment can lead to the reduction of crime because the idea of prison can deter criminals and criminals are removed from society. The retributivism theory relies more on the idea of a social consensus on what is deemed a moral wrongdoing and criminals who commit crimes deserve to be punished [7]. If we had the power to control weakness of will and modulate willpower, this could be very powerful when applied to crimes that are associated with a weakness of will, perhaps those that involve illicit drugs, alcohol, or even the more heinous pedophilia, as specifically discussed in this previous blog post. However, then the justification of additional punishment according to the utilitarian viewpoint would be less valid, since the stimulation alone would potentially reduce crime. In this situation, a criminal would be giving up some level of free will in the name of societal benefits, so one could argue that electrical stimulation could be considered similar to jail time, a punishment that removes freedom and the ability to make many choices from perpetrators’ lifestyles. In this sense, additional punishment according to the retributivism theory would also be less valid since the electrical stimulation would be punishment enough. Finally, there is an additional possibility that is being explored by neuroscientists like David Eagleman who believe that our retributivist justice system (resulting in an overcrowded prison system) should be revised to one focused on rehabilitation, or rather neuro-rehabilitation [8, 9, 10]. Even in the name of rehabilitation though, does such a crime exist that justifies the punishment of nonconsensual direct manipulation of neuronal networks? Having the strength and the will to persevere is most likely a characteristic that we all want all the time, but is choosing not to persevere still a choice that we are always entitled to make, regardless of the context of the choice?





References:



1) Parvizi, J. et al. (2013). The Will to Persevere Induced by Electrical Stimulation of the Human Cingulate Gyrus. Neuron 80, 1359.

2) Rudebeck, P.E. et al. (2006). Separate neural pathways process different decision costs. Nat. Neurosci. 9, 1161.

3) Shackman, A.J. et al. (2011). The integration of negative affect, pain and cognitive control in the cingulate cortex. Nat. Rev. Neurosci. 12, 154.

4) Seeley, W.W. et al. (2007). Dissociable intrinsic connectivity networks for salience processing and executive control. J Neurosci. 27, 2349.

5) Greene, J.; Cohen, J. (2004). For the law, neuroscience changes nothing and everything. Phil. Trans. R. Soc. Lond. B 359, 1775.

6) Bernstein, R.F. (1979). Legal Utilitarianism. Ethics 89, 127.

7) Scheid, D.E. (1983). Kant's Retributivism. Ethics 93, 262.

8) Eagleman, D.The Brain on Trial. (2011). The Atlantic. Retrieved on April 7, 2014 from http://www.theatlantic.com/magazine/archive/2011/07/the-brain-on-trial/308520/.

9) A novel addiction therapy: The real-time fMRI. Initiative on Neuroscience and Law. Retrieved on April 7, 2014 from http://www.neulaw.org/research/real-time-fmri. 

10) Rommelfanger, K. (2011). Neuro-rehabilitation: A vision for a new justice system. The Neuroethics Blog. Retrieved on April 7, 2014, fromhttp://www.theneuroethicsblog.com/2011/10/neuro-rehabilitation-vision-for-new.html



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Strong, K. (2014). Can free will be modulated through electrical stimulation? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2014/04/can-free-will-be-modulated-through_8.html

Brain Matters 3 Conference! Values at the crossroads of Neurology, Psychiatry, and Psychology

*Deadline for abstract submissions: May 15, 2012* 

Brain Matters 3: 

Values at the Crossroads of Neurology,

Psychiatry and Psychology 

October 24th-25th, 2012

This conference provides a venue for
collaboration and learning in the area of neuroethics. The plenary
speakers of this conference will address ethical challenges in the
treatment and research for conditions with neurological symptomatology
but that are without identifiable biological correlates/causes. The
complexities of suffering and disability experienced by individuals with
these conditions are significant, including exposure to dangerous and
futile treatments.

Parallel sessions will include accepted
abstracts from a broad range of neuroethics interests.  At this
conference, presentations will be given by patients, physicians,
neuroscientists, and ethicists and is intended to appeal to a broad
audience.  Please see the call for abstracts and conference information
at http://www.clevelandclinic.org/BrainMatters3.

The submission form is directly available at: http://my.clevelandclinic.org/Documents/Bioethics/abstract-submission-form.pdf




Applicants

We invite scholars from the fields of neuroscience, ethics, philosophy, law, medicine, and

other relevant disciplines to submit abstracts for oral or poster presentations on topics that

fall at the intersection of neuroscience, society, and ethics. Abstracts from trainees and junior

scholars are especially encouraged.

Topics

Abstracts may address a wide variety of topics related to neuroethics, including topics

unrelated to conference theme. These topics could be clinical, research, policy, or theoretical

perspectives in neuroethics. Accepted abstracts will demonstrate scholarly excellence, an

innovative approach, and relevance to neuroethics.

Format

We welcome abstracts in standard scientific format (introduction, methods, results, and

conclusion) as well as traditional scholarly format (clear background, thesis, and argument)

in a fillable PDF form available at www.clevelandclinic.org/BrainMatters3. Abstracts should

be no more than 250 words. Multiple submissions are permitted.

Submission Process

Please email the completed abstract PDF form to neuroethics@ccf.org by May 15, 2012. Early

proposals are encouraged. Submissions received after May 15, 2012 will not be considered.

Conference Registration

Email notification of acceptance will be sent before July 15, 2012. There will be a two-week

opportunity to confirm attendance at the conference once notification has been sent. All

participants must register for Brain Matter 3 and are responsible for their travel, lodging

expenses, and registration fees for the conference. Registration will open in June 2012.

Attendance is required for accepted submissions to be included in the program.

*Please note that the number of attendees will be limited due to meeting space restrictions, therefore early registration is strongly encouraged.*

Want to cite this post?


Rommelfanger, K. (2012). Brain Matters 3 Conference! Values at the crossroads of Neurology, Psychiatry, and Psychology. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/brain-matters-3-conference-values-at.html