Tuesday, November 6, 2018

Medicine & Neuroethics: Perspectives from the Intersection

By Somnath Das

Image courtesy of publicdomainpictures.net.
The first year of medical school is infamously rigorous – it both challenges and changes virtually anyone who dares to undertake it. My experience with this trial was certainly not unique. Despite the knowledge I have gained (on paper, at least), I greatly missed learning about a passion of mine: neuroethics. June marked the two-year anniversary of my attending the Neuroethics in Paris study abroad course hosted by Emory University, which served as the foundation of my exposure to this field. I additionally had the pleasure of taking a graduate neuroethics course offered by the Emory Center for Ethics Masters of Bioethics Program during my time at Emory, which was a more rigorous, yet very essential and fulfilling, dive into the field. Given my previous exposure, it felt odd to begin medical school with little opportunity to formally engage in the field of neuroethics. While my experience with the first year of medical school did not include formal content in neuroethics, I couldn’t help but notice multiple parallels between the two fields, which I will briefly discuss in this blog post. Ultimately, it is my belief that physicians must pay attention to, study, and engage in the field of neuroethics. In this post, I illustrate the reasons for holding this belief by highlighting some of the critical discussions present in both fields; it is my hope that these debates balloon to involve many doctors and patients in the near future.

Cognitive Enhancement  

Different and sometimes conflicting concerns spring up when debating cognitive enhancement for healthy individuals from neuroethical versus medical ethics perspectives. In seeking to address this debate from the biomedical perspective, medical ethicists often choose to focus on measurable cognitive benefits (improvements in memory or concentration), adverse effects (stimulant side effects or stimulant-drug interactions), patient autonomy, and informed consent. The distributive justice of cognitive enhancers is also of concern to medical ethicists, being that physicians currently possess significant financial incentives, under the current medical model to prescribe pharmacological stimulants (Cheung & Pierre 2015). Neuroethicists add to the discussion by debating the ethics of both current and future neuroscientific advances in the field of cognitive stimulation (Racine 2010, pg 10). I have previously written about how neuroethicists, in a similar vein to medical ethicists, voice concern over how individuals with more financial resources can use enhancement to gain an unfair cognitive advantage in society; however, others in neuroethics have argued that healthy individuals should have the right to use enhancement at will, being that stimulation may be necessary to adapt to a more cognitively-demanding future (Clark 2014). Indeed, some bioethicists, such as Arthur Caplan note that cognitive enhancement should “always be done by choice, not dictated by others.” Greely et al. adopts a similar view, noting that the cognitive enhancement debate should not focus on “when,” but rather “how” future leaders mitigate the risks and maximize the benefits of stimulants (Greely 2008).

By emphasizing the ethics of neuroscientific advancements, neuroethicists have pointed out the need to further study the motivations for healthy individuals to seek enhancement. In fact, some neuroethics literature has demonstrated that users may seek enhancement due to less medically quantifiable benefits such as “increased energy” as opposed to increased performance on cognitive tasks (Illeva & Farah 2013). A more complete understanding of the motivations of cognitively healthy individuals seeking to further enhance their abilities will inform the role physicians should play in the future of enhancement distribution (Forlini, Gauthier, & Racine 2013; Chatterjee 2017). These motivations are particularly important to assess as people resort to do-it-yourself (DIY) methods of brain enhancement.

Image courtesy of Flickr user, A Health Blog.
For example, there is a growing community of individuals experimenting with transcranial direct stimulation (tDCS) devices, often broadcasting their results via scientifically unregulated forums such as YouTube. Wexler (2017) argues that the rise in DIY-tDCS should be viewed within the broader growth of the “neurohacking” movement, which she observes is primarily focused on self-improvement of neural abilities (as opposed to a pushback on science and its authorities). Wexler notes that understanding the motivations of healthy individuals for seeking enhancement is important, in that it “might be useful in terms of predicting whether or not users might go ‘underground’ in response to regulation.” As neuroscientists continue to push for advancements in brain enhancement (Farah 2012, pg 580), the ethical ramifications of laboratory and clinical experiments will become inevitably more complex. When this increasing ethical complexity is combined with the fact that society at large is demanding more from human brains and scientific information is rapidly becoming democratized, I believe that physicians bear an increased onus of responsibility to translate the findings of neuroscience to best help their patients achieve their life goals with the help of scientific advancements while avoiding significant harm.

Advanced Neural Diagnostics & Patient Privacy 

The advancement of brain imaging has greatly changed how we think about the nature of using cognitive data for research. The predictive capacity of advanced diagnostics for psychiatric and neurological disorders remains a hotly debated topic. In their response to the Nature article “Attention to Eyes Is Present but in Decline in 2–6-Month-Old Infants Later Diagnosed with Autism,” neuroethicists Karen Rommelfanger & Jennifer Sarrett note that clinical investigators stand as some of the last and most important arbiters of clarifying the nature of imaging data to patients. As brain imaging becomes increasingly complex and precise, it will be necessary for physicians to play an ever-increasing role in constructing the guidelines by which these techniques are used in clinical practice to ensure both informed consent and responsible use and interpretation of data. 

It is necessary to note that physicians have the responsibility to not only clarify the nature of medical data collection, but also to protect this data from being used irresponsibly. In 1996, HIPAA introduced further regulations as to what information is considered “protected,” and it created protocols for the transmission of this information via physical and electronic methods. Within their first weeks of medical school, medical students are introduced to HIPAA, and the importance of protecting patient data persists within both scientific and medical training. However, with the advancement of brain imaging the very nature of what data physicians collect on patients is rapidly changing, potentially to the point where neural data is now too sensitive to be transmitted without further legal change. 

Image courtesy of Flickr user, amenclinicsphotos ac.
Martha Farah has written extensively about the ability of brain imaging to capture complex neural data, such as individual personality traits. This observation raises the question: what if this data can be traced back to the individuals despite randomization and privacy protections? Farah notes that under the current legal framework, “functional brain images can be obtained with consent for one purpose but later analyzed for other purposes” (Farah 2012, pg 578).  Perhaps a more important question is, who owns this data? Future physicians are taught that once a patient’s medical information is stored within the hospital medical records system, patients lose a significant locus of control over their data. As neural data becomes more complex, and therefore more traceable back to individuals, would [and can] physicians exert the same privacy protocols and protections codified in HIPAA? The answer remains unclear, and the future will involve significant engagement of perspectives from ethicists, physicians, and patients to ensure the safety of the most sensitive types of medical data. 

Conclusion

The future of medicine is intimately tied to emerging neurotechnologies, and therefore will require a keen understanding of what motivates the public to seek new technologies and how the public conceptualizes these technologies in terms of risks, benefits, and long-term impacts. Gaining this understanding will help physicians and neuroethicists alike to protect individual patient safety and privacy. I believe the physician can serve as the strongest bridge between the worlds of academia and individuals who will be impacted by this technology. This idea is hardly new; from transplantation to novel cancer therapeutics, physicians stand to interpret the intersection of what is possible and what needs to be done in order to heal the patient. Being that some technologies may do more harm than good, the “ideal” physician ultimately should serve to protect their patient from the dangers of novel technologies when the risks outweigh the benefits. It is through proper training and exposure to neuroethics that I believe physicians can better treat their patients and be more adequately prepared to address the future of what is to come in modern medicine. 
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Somnath Das is a second year student at Sidney Kimmel Medical College. His interests currently involve integrating neuroethics education into the training of future medical professionals. His interest began at Emory University under the instruction of Dr. Karen Rommelfanger, and he still enjoys occasionally contributing to the blog to this day. The implications of futuristic technologies both within and outside medicine interests him, and he views Neruoethics as a toolbox to think, debate, and perceive the sequelae of the latest neuroscientific innovations.



References

Clark, V. P., & Parasuraman, R. (2014, 01). Neuroenhancement: Enhancing brain and mind in health and in disease. NeuroImage, 85, 889-894. doi:10.1016/j.neuroimage.2013.08.071

Chatterjee, A. (2017). Grounding ethics from below: CRISPR-cas9 and genetic modification. The Neuroethics Blog. Retrieved on July 24, 2018, from http://www.theneuroethicsblog.com/2017/07/grounding-ethics-from-below-crispr-cas9.html

Davis, J. K., Hoffmaster, B., & Hooker, C. (n.d.). Pragmatic Neuroethics. Retrieved from https://mitpress.mit.edu/books/pragmatic-neuroethics

Farah, M. J. (2012, 01). Neuroethics: The Ethical, Legal, and Societal Impact of Neuroscience. Annual Review of Psychology, 63(1), 571-591. doi:10.1146/annurev.psych.093008.100438

Forlini, C., Gauthier, S., & Racine, E. (2013, September 03). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3761009/

Greely, H., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., Campbell, P., & Farah, M. J. (2008, December 10). Towards responsible use of cognitive-enhancing drugs by the healthy. Retrieved from https://www.nature.com/articles/456702a

Ilieva, I. P., & Farah, M. J. (2013). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3813924/


Racine, E. (2010). Pragmatic neuroethics: Improving treatment and understanding of the mind-brain. The MIT Press.

Wexler, A. (2017). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423946/


Want to cite this post?

Das, S. (2018). Medicine & Neuroethics: Perspectives from the Intersection. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2018/11/medicine-neuroethics-perspectives-from.html

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