“Dans le doute, mon cher… abstiens-toi”1?

If science has one defining tenet, it would be the pursuit of knowledge. By pushing boundaries and expanding the horizon of the possible, science itself seems antithetical to the old adage "Where ignorance is bliss, 'tis folly to be wise."² But the philosophy of truth and the reality of its application are two very different things. As clinicians’ ability to diagnose conditions earlier and earlier improves, a complex ethical issue arises. Where exactly does one draw the line between the bliss of ignorance and the benefits of knowledge? Such a debate hinges on two questions: What are the inherent ramifications of that knowledge, and what benefits does it grant. The first question is the more complex, as it begs at the very ontology of disease, when knowledge is but an echo of future sorrow, whose ears wish for such a burden. Yet by knowing the future, you can prepare. Thus knowledge, in itself, of a future disease or disorder is a double edged blade. It cuts through the wilds of uncertainty, but not without drawing the blood of its wielder. The second question is less metaphysical. As the science of bio-markers improves and genetic screenings become commonplace, disease may become as predictable as the weather. If this prediction permits valuable treatment that could turn the tide of fate, then aren’t all the difficulties of knowing, suddenly so much less damning? Healthcare as we know it could be transformed. People will no longer get disorders, they will get antidotes. When knowledge offers a way out of doom, only the fool would cover his ears.

This bright future is not yet upon us though. So we must balance the state of preventative medicine with the risk of false diagnosis, because as anyone who has been caught unprepared by a mid day rain shower knows, predictions are only predictions, and even the most reliable forecasts can be very wrong. When the predictions are about your health and the forecasts prescribe intense treatment, the costs of error suddenly become much greater. For most disorders, adequate early treatment does not yet exist, so all the risks and all the sorrow of impending fate seem without reconcile. But knowledge begets knowledge, and as science pushes forward the benefits granted by early diagnosis will only improve. And if we do not begin with early diagnosis, scientists will be unable to properly track how diseases and disorders develop over time. Early diagnosis also offers a pool of subjects for clinical trials. Finding the at-risk population is the first step towards treating them. The science of medicine is inexact, but for it to improve, sometimes difficult steps must be taken. When knowledge of doom is only that, it seems better not to know. But herein lays the role of science: doubt need not leave us frozen in inaction. From doubt, science can weave truths. Only by embracing the scattered pieces of knowledge, can those pieces be formed into more coherent wholes. For the time being, it can only be voluntary that people should submit themselves for early diagnostic screening. And by doing so they may not help themselves, but they will likely be invaluable in helping the future.

--Dan Curry

Neuroscience Graduate Program

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Curry, D. (2011). “Dans le doute, mon cher… abstiens-toi”? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2011/12/dans-le-doute-mon-cher-abstiens-toi.html

Sources

1 Leo Tolstoy, War and Peace, 1869.

2 Thomas Gray, Ode on a Distant Prospect of Eton College, 1742.

Ethical Implications of Diagnosing High-risk for Schizophrenia

In the last decade, there has been a push to develop and characterize a diagnosis for adolescents at high-risk for schizophrenia, called prodromal risk syndrome.¹ The Personal Assessment and Crisis Evaluation (PACE) clinic in Melbourne, Australia, was first to develop a classification of prodromal syndromes.² The disease of schizophrenia is most typically diagnosed in early adulthood, when most schizophrenics experience their first psychotic break, therefore, early intervention tactics are aimed at adolescents. This is one of the reasons that the PACE clinic is located in a shopping mall.³

On the other side of the globe, the North American Prodrome Longitudinal Study (NAPLS) has been developing and improving methods to reliably diagnose individuals in the prodrome stage. Once identified, they offer these individuals psychotherapy, family therapy, drugs, or cognitive training to hopefully lessen the progression of symptoms. Their method of assessment scores symptoms including family history of psychosis, unusual or fragmented thoughts, school or social troubles, as well as peculiar emotions, behaviors, and thinking, such as; paranoia. After following the individuals for two years, they developed an algorithm that successfully predicts progression to schizophrenia with an accuracy rate of 80%.¹ While this is an impressive rate of accuracy, many ethical implications are raised by both the existence of false positives and true positives. 

Regarding the false positives, individuals deemed high-risk who are actually not at risk of developing schizophrenia, one of the first issues deals with the effects of diagnosis and treatment. Anti-psychotic drugs can have side effects that may include excessive weight gain, galactorrhea, sedation, sexual side effects, and mild dystonia.^4,5 Some side effects of diagnosis, however, might be more hidden. The stigma involved may affect the patient's and family's expectations for the future, altering their choices in terms of employment, schooling, and life goals.⁶ This is a high price for an individual to pay if they otherwise would not have seen many consequences in their life. 

For those individuals who are true positives, there are also sacrifices made in the interest of early intervention. For many individuals who develop schizophrenia, their pre-symptomatic years are a period of time during which they have the best likelihood of living a life of normalcy. The potential of effective treatment needs to be weighed with the effect of tainting this pre-symptomatic period with knowledge of an impending lifelong struggle with mental illness. This cost increases with any shift towards earlier diagnosis or diagnosis in a less symptomatic population. If encouraging results from prodromal research are found, then many parties, including researchers and drug companies, will inevitably push for earlier and earlier diagnosis.⁶

Finally, for anyone receiving a prodomal diagnosis, there are many risks involving third parties such as insurance agencies, schools, employers, and peers.¹ Families need to be informed of the possible effects of disclosing medical information such as this, but patients and families may not always foresee the consequences involved.

One area in which the cost and benefit balance may be addressed is in who is targeted for screening. Most of the research done to this point has been on help-seeking families who have noticed something wrong and are looking for answers and treatment. This population's current quality of life may already be affected, they may be more symptomatic, and they may be more likely to view the early diagnosis as a cause for hope as opposed to a reason for despair.⁶ There will always be pressure, however, from competing interests that would rather expand the patient base through earlier and more widely applied screening. It is therefore imperative that we address these issues involving the interests of the patients before those with other financial incentives are permitted to steer the direction of the field.

--Kevin Watkins

Neuroscience Graduate Program

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Watkins, K. (2011). Ethical Implications of Diagnosing High-risk for Schizophrenia. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2011/12/ethical-implications-of-diagnosing-high.html

References

1. Dobbs, D. Nature 468, 154-156 (2010).

2. McGorry, PD, Yung, A., & Phillips, L. Schizophr Res. 51, 17-29 (2001).

3. Yung, A.R. et al. Schizphr Bull. 22, 283–303 (1996).

4. Correll, C.U. et al. Biol Psychiatry 55, 147S (2004).

5. Tsuang, M.T. et al. Biol Psychiatry 45, 1412-1418 (1999).

6. Corcoran, C., Malaspina, D., & Hercher, L. Schizophr Res. 73, 173–184 (2005).

The Risks of Schizophrenia: Is Early Intervention Always Beneficial?

John Forbes Nash Jr. was a brilliant mathematician at Massachusetts Institute of Technology when in 1959 he began to exhibit extreme paranoia and erratic behavior. Later that year, he would check into a mental hospital where he would be diagnosed with schizophrenia. Although over 50 years have passed since that time, schizophrenia has no cure, no well-defined cause, and no means of prevention.

Schizophrenia is debilitating and extremely costly, not only to patients and their families, but also to society at large. Approximately 1% of the world's population will be diagnosed with schizophrenia within their lifetime. Recent research has focused on identifying individuals at the highest risk before the full onset of psychosis, but these efforts have proven highly controversial due to ethical concerns.

The North American Prodrome Longitudinal Study (NAPLS) has championed efforts to characterize the schizophrenia prodrome, which is defined as early symptoms of the disease that may be used to identify schizophrenia patients prior to the onset of full psychosis.^1-2 The participants in these studies are already seeking medical help due to psychological symptoms or behaviors that the patients or their families find alarming. Often, these symptoms are already interfering with the patients' daily lives. In order to be classified as prodromal, the patient must fit one of three criteria: 1) exhibition of attenuated positive symptoms (such as hallucinations or delusions) associated with schizophrenia, 2) brief periods of fully psychotic positive symptoms, or 3) a recent deterioration in function and a family history of psychosis.³ We must be careful to distinguish these high risk patients from schizophrenia patients: having a high risk of contracting a disease is not equivalent to having the disease itself.

Prodromal patients often receive antipsychotic or antidepressant medications as well as cognitive and behavioral therapy.⁴ These treatments may help delay the onset of full psychosis and lessen the severity of disease symptoms once they occur. Indeed, this claim has received some support from recent research, and future research aims to increase the efficacy of these treatments.^{5, 6} The potential benefits of this research are undeniable, but what are the costs?

The social stigma attached to schizophrenia is deeply rooted in our society. People unfamiliar with prodrome research might incorrectly assume that the prodrome patient has schizophrenia, therefore prodrome patients may be subject to the same stigma. Although researchers and clinicians maintain patient confidentiality, they cannot prevent patients or their parents from sharing information with their friends and extended family. From there, the information may reach neighbors, teachers, and employers. The potential consequences of association with a prodromal study are numerous and can be detrimental for the patients involved.⁵

 

As prodrome research undergoes refinement, researchers become better equipped to identify patients destined for schizophrenia. Yet inevitably some prodromal patients prove to be false positives: they will never develop schizophrenia. According to some estimates, false positives account for 50-85% of prodromal patients, but this figure may be misleading.^1,2,5 Because prodromal patients often undergo preventative treatment, some of these patients may be "false" false positives: intervention halted disease progression but without that treatment they would have descended into full psychosis.⁵ However, many false positives truly represent individuals who never would have developed schizophrenia, even in the absence of medical intervention. These individuals probably have little to gain from preventative treatments yet suffer from unnecessary social stigmas and medication side effects. Future research should aim not only to minimize the number of people within this category, but also the risk of unintentional harm inflicted upon them as a result of their participation in prodromal studies.

Greater refinement in prodrome research also promises to identify prodromal patients earlier in their lives, perhaps even before the onset of obvious symptoms. This early identification could further improve the outcome for schizophrenia patients but also threatens the period of relative normalcy that patients enjoy before disease sets in.⁵ We might think of this as a time of blissful ignorance when patients can enjoy life without the anxiety of impending disease. If researchers can identify patients during this time, do they have a responsibility to do so, or should they let these patients enjoy this time uninterrupted by psychiatric exams and medications, especially when they cannot offer a cure?

After his psychotic episode in 1959, John Nash would go on to win the 1994 Nobel Prize in Economics for work done while he was a graduate student in his mid-twenties. In 2001, his story as depicted on the silver screen in A Beautiful Mind would astound audiences worldwide. But what if Nash had lost the period of relative normalcy he enjoyed prior to 1959 when he was doing his greatest work? If current knowledge of the schizophrenia prodrome had been available to Nash's parents in the 1940s, perhaps they would have found some aspect of their teenage son's behavior cause for concern. After clinicians identified their son as prodromal, they might have placed him on antipsychotics and into therapy. They, as well as his teachers, might have dissuaded him from pursuing his dreams of mathematical greatness and encouraged him to pursue a career "more appropriate" for someone with his condition. His medications might have interfered with his outstanding cognitive abilities. Would a teenage Nash resist these limitations, or would he feel so anxious about his own condition that he would admit defeat in the face of impending disease? Perhaps medical intervention would have lessened the severity of John Nash's symptoms, but we cannot easily predict the consequences this intervention would have had on his life.

--Kristen Thomas

Neuroscience Graduate Program



Want to cite this post?


Thomas, K. (2011). The Risks of Schizophrenia: Is Early Intervention Always Beneficial? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2011/12/risks-of-schizophrenia-is-early.html

References

1. Dobbs, D. Nature 468, 154-156 (2010).

2. Chuma, J. & Mahadun, P. BJP 199, 361-366 (2011).

3. Woods, S.W. et al. Schizophrenia Bulletin 35, 894-908 (2009).

4. Tandon, R, Nasrallah, H.A. & Keshavan, M.S. Schizophr Res 122, 1-23 (2010).

5. Corcoran, C., Malaspina, D. & Hercher, L. Schizophr Res 73, 173-184 (2005).

6. Perkins, D.O. et al. Am J Psychiatry 162, 1785-1804 (2005).

First Installment: First Year, Neuroscience Students at Emory Write About the Neuroethics of Schizophrenia and the Prodrome

This year, Emory's First Year Neuroscience Graduate Students were asked to write a blog post for the Neuroethics portion of their Neuroscience and Communications Course.



These posts will be delivered in 4 weekly installments, each week featuring a commentary on a different neuroethics piece.



This week, we feature blogs covering the following article:



Schizophrenia: The making of a troubled mind Nature 468, 154-156 (2010)

Want to cite this post?


Rommelfanger, K. (2011). First Installment: First Year, Neuroscience Students at Emory Write About the Neuroethics of Schizophrenia and the Prodrome. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2011/12/first-year-neuroscience-students-at.html

Welcome Our Inaugural Neuroethics Scholars!

It is with great pleasure that the Emory Neuroethics Program announces its inaugural neuroethics scholars!  The Neuroethics Program invited graduate students to create and to join collaborative, interdepartmental faculty teams at Emory and in the Atlanta community to pursue Neuroethics scholarship.  Graduate students were free to propose projects of interest to them. Proposals included innovative ideas in the arena of teaching, empirical research, new media, and beyond. By the completion of their one year appointments, each scholar is expected to co-author a paper and present his/her work.  The selection process was quite competitive. Abstracts of their proposed projects can be found below.





Cyd Cipolla and Kristina Gupta (Innovative Neuroethics Teaching)

Cyd Cippola and Kristina Gupta

We both work in the field of feminist science studies, a field that has challenged the gender biases of scientific knowledge. In her dissertation research, Cyd examines the role of religious, psychiatric and popular representation in the creation of “violent sex offender” legislation in the United States, and the relationship between this criminal category and sexual identity categories. In her dissertation research, Kristina examines the interplay between scientific and medical approaches to “nonsexuality” and the efforts by some individuals to define “asexuality” as a sexual identity category. Through our research, we both became interested in the role that neuroscientific research plays in defining some types of sexuality as deviant or pathological and in influencing public understandings of certain types of sexuality.

Based on this interest, we applied to the Neuroethics Scholars Program both to increase our own knowledge about the field of Neuroethics and to contribute to this emerging field. As Neuroethics scholars, we will develop and teach a course during the spring of 2012 titled “Feminism, Sexuality, and Neuroethics.” The course is being offered through the Department of Women’s, Gender, and Sexuality Studies and is cross-listed with the Department of Neuroscience and Behavioral Biology. Students in this class will learn the major topics and themes within the field of Neuroethics through critically examining historical and contemporary scientific research on sexuality and the brain. We will cover a variety of topics, including homosexuality, sex/gender differences in sexuality, violent sexual offenses, sex addiction, sexual desire disorders, and monogamy. Students will read a scientific study or studies on the topic alongside reports about the study in news media outlets, and then follow this by reading critiques of the work from both inside and outside the scientific community. No previous experience with neuroscience research or sexuality research is required to take the class. Our goal is to enable students from all disciplines to understand the scientific research on its own terms, to develop the skills required to analyze the ethical implications of this research, and to develop an understanding of how neuroscientific research is conveyed to the public through media.

In addition to teaching the course, we plan to make our syllabus publicly available and to write an article reflecting on our experiences teaching the course. In this way, we will contribute to the resources available for teaching about Neuroethics. We are very excited about this opportunity and we look forward to sharing our experiences with you. We would also appreciate any feedback, suggestions, or advice you have to offer!

 





Jason Shepard (Innovative Empirical Neuroethics Research)

Jason Shepard

I am interested in exploring the links between beliefs in free will and pro- and anti-social behaviors. Some neuroscientists and psychologists often claim that data from the brain and behavioral sciences are providing evidence against the existence of free will. These claims range from the more modest (but still controversial) claims that the data is showing that our free will is much more limited than we suppose to the much stronger claims that the data is showing that free will is an illusion. These anti-free-will claims are no longer confined to the pages of academic journals; these claims have also been regularly making their way into the popular media. In a separate line of research, psychologists have experimentally demonstrated that by exposing people to texts that claim that free will is an illusion, people tend to cheat more (Vohs & Schooler, 2008) and they tend to be less willing to help and tend to be more aggressive (Baumeister, et al , 2009). These findings have raised some important ethical questions such as: If exposing people to anti-free-will texts can have deleterious effects on people’s behaviors, might there be harmful social consequences of scientists publically making anti-free-will claims? If there are harmful social consequences of scientists publically making anti-free-will claims, are there any ethical constraints placed on those who might be tempted to publically make anti-free-will claims? Though the current evident suggests that these are questions that deserve serious attention, the current evidence does not yet justify an answer to these questions. From the current studies is not really clear what are the specific mechanisms that lead to reduced beliefs in free will and the behavioral changes, whether the results will generalize beyond the lab , or whether the behavioral effects will persist beyond a single testing session. All of these issues need to be adequately addressed in order to have a clear understanding of what exactly is at stake, whether the stakes warrant any proscriptive advice, and what exactly should be the content of the proscriptive advice. In order to help answer these questions, Jason proposes (1) to explore the specific mechanisms that can lead to reduced beliefs in free will at a finer grain level than previous studies; (2) to try to generalize the results to a wider range of ecologically valid measures of pro- and anti-social behaviors; and (3) to explore the time course of the behavioral effects.


Jason Shepard is a first-year psychology PhD student in the Cognition and Development Program at Emory, where he works in Phillip Wolff’s Cognition and Linguistic Systems Lab. He also holds an MA in philosophy with a concentration in Neurophilosophy from Georgia State University. In addition to studying the behavioral effects of beliefs in free will, Jason also studies intentional action, causal structure, and other related phenomenon.







Want to cite this post?


Rommelfanger, K. (2011). Welcome Our Inaugural Neuroethics Scholars! The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2011/11/welcome-to-our-inaugural-neuroethics.html





References



Baumeister, R., Masicampo, E.J., DeWall, C. N. (2009) Prosocial Benefits of Feeling Free: Disbelief in Free Will Increases Aggression and Reduces Helpfulness. Personality and Social Psychology Bulletin, 36, pp. 260-268



Vohs, K. and Schooler, J. (2008). The value of believing in free will: Encouraging a belief in determinism increases cheating. Psychological Sciences, 19, pp 49-54.

"The Ethics of Designer Brains": Interview with Paul Root Wolpe on Big Think

Director of Emory's Center for Ethics talks about the ethics of designer brains on Big Think.

"Our values as a society will determine which psychopharmaceuticals and (down the road) which genetic enhancement technologies we choose to develop and how we use them.


That's what concerns Dr. Paul Root Wolpe, senior Bioethicist at NASA and a pioneer in the field of neuroethics. Peering into his children's and grandchildren's future, he sees an America that rewards competitiveness and productivity over relationship-building, and suspects that future generations will face intense pressure to enhance their minds and bodies in unhealthy ways.



The politics of technophilia vs technophobia aside, our power to manipulate our brains and genes is increasing dramatically – and it raises serious ethical questions."

Neuroethics Journal Club documented by artist Jon Ciliberto

Jon Ciliberto artist and all around jack-of-all-trades documented our last Neuroethics Journal Club on Neurotechnologies and Lie Detection via painting/drawing.  Thanks, Jon!

by Jon Ciliberto

Our next Neuroethics Journal Club will be on December 14, 2011. We will be discussing the AJOB Neuroscience article, "Deflating the Neuroenhancement Bubble," and Emory Neuroscience Graduate student David Nicholson will facilitate this session.