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Only a subset of individuals will develop post-traumatic stress disorder (PTSD) after exposure to a traumatic event (Yehuda, 2004), even though an individual will experience at least three traumatic events in their lifetime (Benjet et al. 2016). That said, predicting who will and who will not develop PTSD in the future is of particular interest and importance, especially for members of law enforcement agencies, such as the police or military forces. Police agents and military soldiers are particularly at higher risk of developing PTSD due to their professions which comprise facing serious traumatic events including traffic accidents, (mass) shootings, armed threats, or even war combat. Rates of PTSD among military personnel and police officers are significantly greater when compared to the general population (Weichselbaum et al. 2017).

The current literature looking into the underlying mechanisms involved in onset of PTSD are not entirely understood. Despite the presence of several gaps in better understanding this stress-related disorder, we know for sure that PTSD is linked with dysregulation in multiple biological and physiological functions; these together cause a variety of changes in the brain leading to the manifestation of the disorder (Daskalakis et al. 2018). Increasingly, research looking into the identification of biomarkers – such as brain imaging, behavioral and cognitive measurements, estimations of particular genes and proteins found in blood, urine and saliva — is making headway (Schmidt et al. 2013). For instance, our group has shown that changes in DNA methylation in particular genes are correlated with changes in clinical symptoms of PTSD, suggesting that epigenetic differences may exist between PTSD resilient and susceptible individuals (Rutten et al. 2018).

Prediction of PTSD susceptible and resilient individuals does not come without its ethical implications, which we must confront in a proactive manner, that is, before this application becomes routine procedure in the clinic.

To date, discussions concerning biomarker research in stress-related disorders are not expansive. Those that are reported mostly cover research-related challenges (Jain et al. 2011), ethical implications around the treatment of PTSD patients (Yang et al. 2017), and more on issues that pertain to the criminal justice system (Soltis et al. 2014). However, what we have identified as underrepresented ethical issues pertain explicitly to the context of prediction and prevention of PTSD (Bassil, Rutten, and Horstkötter 2019).

Avoidable cases of PTSD

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With current developments in the field of biomarker research, can we with some accuracy predict who will develop PTSD and, as such, avoid increasing the incidence of PTSD? Having biomarkers that can predict with some accuracy the risk to develop PTSD and not translating this research to the bedside can be considered a moral failure. Think of the many cases of PTSD that could be prevented or better managed if we were to know in advance that an individual carries increased biological vulnerability to develop this psychiatric condition. For instance, an early detection of PTSD susceptible individuals might allow clinicians to focus on that subgroup with the aim of better developing specific early interventions if a person were to experience a traumatic event at some point. Cognitive behavioral therapy (CBT) introduced within a few months of a traumatic event has been shown to be effective in populations being at risk of developing PTSD (National Collaborating Center for Mental Health, 2005). This is not to say that those that are not susceptible to PTSD should be neglected, but those carrying certain biological vulnerabilities should be assisted in particular ways to minimize their risk of developing a debilitating mental disorder. When it concerns the police or even soldiers, it remains questionable whether not deploying them to the field – where chances of experiencing a traumatic event are high – would be the right thing to do.

While we cannot put stops to experiencing traumatic events in one’s life, this becomes particularly important when it concerns members of law enforcement agencies who on a daily basis are voluntarily exposed to traumatic and stressful events. Many might argue that current applications are not efficient enough to make such conclusions (Schmidt, Kaltwasser, and Wotjak, 2013), but what is worse— being only 80% right or 20% wrong and not doing anything about it?

You are Susceptible

If biomarker-based findings become standard practice (Lehrner and Yehuda, 2014), a series of ethical questions arise on the implications of such a procedure. For instance, currently we wouldn’t know how to apply such a procedure within law enforcement agencies. Should screenings for PTSD susceptibility become a requirement for recruitment and employment? Will such screenings categorize individuals within an agency, those that are susceptible and not suitable for visiting crime scenes, and those that are resilient and “desired” in war combat, for example? Similar actions might prevent cases of PTSD, by minimizing exposure to traumatic events for individuals with a certain biological vulnerability. In addition, these biomarker-based findings could have crucial importance in informing law-enforcement agency policies. A great example of this is how scientific findings could inform policy making and decisions. But even by taking actions to avoid cases of PTSD, challenges are bound to arise. Questions arise on enforcing such a procedure prior to recruitment, the governance of PTSD susceptible individuals, stigmatization and discrimination in the workplace and on the outside, the impact on the individual’s psychology and self-perception. The technology is probably not here yet, but it’s not out of reach, and these are the questions we should be asking now to tackle these issues proactively and to move in directions that are both ethical and socially responsible.

You are Resilient

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By making use of biomarkers to identify PTSD susceptible individuals, recognizing PTSD resilient individuals is a given. Dual-use is a term that is most often than not linked to neurotechnologies that are researched and developed for military purposes (Kellmeyer et al. 2019). However, dual-use seems to be overlooked when discussing resilience to PTSD. What exactly does this mean in terms of ethical considerations? How does one perceive themselves after learning that they are resilient to PTSD? How will the relationship between employer-employee change after both parties learn of this outcome? Will those that are resilient to PTSD show less empathy to violent situations and suffering of other individuals? Will they be more willing to participate in violent and immoral activities? Will their employer have greater expectations from them? Feelings of guilt and shame have repeatedly been reported by soldiers diagnosed with PTSD after being involved in war combat (Yang et al, 2017), will biomarker-based findings be the end of guilt in these soldiers? This is of particular interest, since moral emotions such as guilt, fear, and shame have been strongly associated with psychiatric disorders, including PTSD (Fontenelle, de Oliveria-Souza, and Moll 2015).

Now what?

It is important to acknowledge that susceptible and resilient individuals do not represent a black and white situation. This dichotomy is a reductionist representation of the actual problem, in reality individuals fall within a spectrum where they are more susceptible than the average or less resilient and vice versa, making this a constantly changing paradigm throughout one’s lifetime. But to make a complex story simpler, we choose to stick to those two extremities.

These questions and ethical challenges remain open and elusive thus far. However with developing neurotechnologies, specifically biomarker research and findings that will enable us to distinguish individuals as being susceptible or resilient to PTSD, there remains both the ethical importance and the moral duty to investigate and contemplate these issues while the technology is being improved and not after it has been implemented in the clinic.

While this post focuses on members of law enforcement agencies, a bigger question remains: what ethical implications may exist in the prediction of PTSD susceptibility and resilience in the general population, especially in light of recent mass shootings, police brutality and terrorist attacks both in America and Europe?

Perhaps the problems will remain the same fundamentally yet with different outcomes.

Katherine Bassil is a Doctoral Fellow at the School of Mental Heath and Neurosciences, at Maastricht University, The Netherlands. She is currently working on a NWO-funded project “Investigating Epigenetic Mechanisms underlying PTSD Susceptibility in a Dutch Military Cohort”. Additionally, her research focuses on the ethical implications of biomarkers for PTSD susceptibility and resilience, and on the use of human neural tissue as a model for brain disorders. Katherine is a frequent contributor to Nature magazine, Massive Science, the Observant newspaper and other. She is also an editorial assistant in Neuroethics Canada, a member of the Student-Postdoc Committee of the International Neuroethics Society (INS) and the founder/host of the first neuroethics podcast: The Neuroethics Police. She hopes that one day she’ll be able to bridge the fields of neuroscience and neuroethics, and inspire others to see the importance of such an effort.