By Erick H. Cheung, MD | June 8, 2010
Dr Cheung is co-chief resident in the department of psychiatry at the Semel Institute for Neuroscience and Human Behavior of the University of California, Los Angeles. The author reports no conflicts of interest concerning the subject matter of this article.
Picture a metallic arm with spectacular titanium and stainless steel exposing inlayed microchips, boasting over 20 points of movement that closely mimic a human arm.
This is the image that graces the cover of National Geographic’s January 2010 issue, heralding the “bionic age.”1 To be clear, it has taken decades for scientists to accept the term “bionic,” which is the merging of man with machine—once just a figment of fiction writers’ imagination. With astoundingly innovative technology, researchers are harnessing motor cortex brain signals that travel to the stump of an amputee’s limb, where electrode arrays are matched with the residual nerve endings to translate the signal into the human-like mechanical motion of a prosthetic limb.
In the field of “brain bionics,” the industry of neurostimulation therapies is a ripe market. Several large corporations and more than 20 start-up companies are competing to find new applications and improve the efficacy of the major, contemporary neurostimulation modalities: deep brain stimulation, spinal cord stimulation, and vagus nerve stimulation (Table 1).2
The future is here.
Neuroethics meets psychiatric ethics
For decades, neuroscientists have been cognizant of the social implications of their work, but only since 2002 has the field of “neuroethics” emerged as a formal discipline that attempts to organize and address the ethical issues in neuroscience research and technology.3 The coining of the term “neuroethics” is credited to William Safire,4 a former columnist for The New York Times, who described it as “the field of philosophy that discusses the rights and wrongs of the treatment of, or enhancement of, the human brain.” A new vernacular has since transpired, with the prefix “neuro” (denoting neuroscience-based or -informed) commonly appended to a suffix such as “ethics,” “ law,” “imaging,” or “enhancement.” Michael Gazzaniga,5 sitting with the 2004 President’s Council on Bioethics, provided a broader definition of neuroethics as the “examination of how we want to deal with the social issues of disease, normality, mortality, lifestyle, and the philosophy of living informed by our understanding of underlying brain mechanisms.”
Neuroethics has a rapidly growing literature that focuses mostly on the ethical concerns in neuroimaging and neuroenhancement. However, there has been a lack of attention from both psychiatry and neuroethics to the potential implications of neuroscience and its technologies for the diagnosis, treatment, and societal perception of mental illnesses.6 Increasingly, sophisticated techniques for imaging and intervening in human cognition, emotion, and behavior raise important ethical issues at the intersection of neurotechnology and psychiatry (Table 2).
Physical manipulation of the brain
Prosthetic limbs, cochlear and retinal implants, mechanical heart valves, kidney dialysis machines, and pain pumps are examples of full- and part-time bionic human parts with cutting- edge technology that extend lives and relieve suffering. Are there any worries about becoming a bionic society? The ethical concerns achieve a sharper focus and reach higher stakes when considering neurostimulation technologies and intervention in brain function. Deep brain stimulation, for example, might soon be proved safe and effective as a means of alleviating a number of treatment-resistant psychiatric disorders, including depression, obsessive-compulsive disorder, and psychosis; yet turning off the depression, the obsessions, or bad thoughts with a neuroimplant somehow raises ethical concerns, whereas hip replacements and hearing aids do not.7
The historical existence of this controversy is apparent when looking back at psychiatry’s experience with electroconvulsive therapy (ECT) and psychosurgery, and the decades of debate waged over patients’ rights and allegations of social and individual mind control, punishment for recalcitrant patients, and concerns about overuse or misuse.8 Despite overwhelming research in support of ECT’s safety and efficacy, this form of treatment still engenders broad skepticism, misunderstanding, distaste, and civil rights protest.
Psychosurgery is a particularly contentious practice, and yet, the outcome of deep brain stimulation may not be all that different. While the true mechanism of action of deep brain stimulation is still unclear, the prevailing theory is that the implanted electrodes create a focal inhibitory effect on the immediate surrounding brain tissue and thus achieve the ablative results similar to those of psychosurgery. Granted, an obvious major advantage to deep brain stimulation is the potential reversibility of an implanted electrode, yet it remains to be seen whether this factor is sufficient to moderate public opinion and engender wider acceptance than that of psychosurgery or ECT.
In speculation, part of the reluctance to intervene physically in brain functions stems from persistent stigma and a general assumption that mental illnesses are to a greater degree under a person’s control than physical illnesses (eg, tremors, seizure, heart valve failure). Furthermore, it appears that emotional and cognitive functions garner a higher degree of sanctity and inviolability than all other human functions. Thus, psychosurgery may seem acceptable or palliative when it is used to relieve intractable seizures, but barbaric when used for treatment-resistant schizophrenia. Likewise, while concerns are raised over a so-called brain pacemaker (the lay term for deep brain stimulation) that can modulate mood and cognition at the “flip of a switch,” people who have Parkinson disease are able to benefit from immediate, dramatic improvements in gait and motor control. Understanding the philosophical and cultural roots of such a discrepancy is a major task for psychiatry and neuroethics. (read HERE)