Neuroethics

Brave New...Rats?

Here is a piece in the latest NewScientist about so-called "rat cyborgs" you might find of interest. It turns out that neurocognitive implants may be closer than we thought.  Here is an excerpt:

Now Matti Mintz of Tel Aviv University in Israel and his colleagues have created a synthetic cerebellum which can receive sensory inputs from the brainstem - a region that acts as a conduit for neuronal information from the rest of the body. Their device can interpret these inputs, and send a signal to a different region of the brainstem that prompts motor neurons to execute the appropriate movement.

This is as exciting as it is scary.  We may be on the cusp of a brave new world indeed!

Beyond Therapy: Essential Sources of Concern

Beyond Therapy: Essential Sources of Concern

President’s Council on Bioethics

Introduction

“Why, if at all, are we bothered by the voluntary self-administration of agents that would change our bodies or alter our minds?  What is disquieting about our attempts to improve upon human nature, or even our own particular instance of it?” (58)

“We are in an arena where initial revulsions are hard to translate into sound moral arguments.”

The morality of modification and the worry about trans-humanism: “Can our disquiet at such prospects withstand rational, anthropologic, or ethical scrutiny?  Taken one person at a time, with a properly prepared set of conditions and qualifications, it will be hard to say what is wrong with any biotechnical intervention that could improve our performances, gives us (more) ageless bodies, or make it possible for us to have happier souls.” (58)

“We sense that it may have something to do with challenges to what is naturally human, what is humanly dignified, or to attitudes that show proper respect for what is naturally and dignifiedly human.  As it happens, there are at least four such considerations:  appreciation of and respect for the “naturally given,” threatened by hubris; the dignity of human activity, threatened by “unnatural” means; the preservation of identity, threatened by efforts at self-transformation; and full human flourishing, threatened by spurious or shallow substitutes.” (59)

Psychiatric Medicine and Sickness

The Chronicle of Higher Education has a new article entitled, "Are Psychiatric Medications Making Us Sicker?" which you may find of interest.  Here is an excerpt:

In retrospect, my critique of modern psychiatry was probably too mild. According to Anatomy of an Epidemic (Crown Publishers, 2010), by the journalist Robert Whitaker, psychiatry has not only failed to progress but may now be harming many of those it purports to help. Anatomy of an Epidemic has been ignored by most major media. I learned about it only after Marcia Angell, former editor of The New England Journal of Medicine and now a lecturer on public health at Harvard, reviewed the book in The New York Review of Books in June. If Whitaker is right, American psychiatry, in collusion with the pharmaceutical industry, is perpetrating what may be the biggest case of iatrogenesis—harmful medical treatment—in history.

I take it this sounds familiar!

Neuroenhancement in The Dickinsonian

Brian Cook '12 wrote a very nice piece for the Dickinsonian entitled, "Concentrating or Cheating?"  It does a good job of capturing much of what we've been struggling with in this section.  So, if you haven't already seen his article, you should check it out!

The Run on Ritalin

Lawrence Diller

“The Run on Ritalin: ADD and Stimulant Treatment in the 1990s”
 

 Here in Ritalin Nation, more than one of every thirty Americans between the ages of 5 and 19 has a prescription for methylphenidate to control their behavior. Use of stimulants has become so common-place in Atlanta that at least 1/3 of their male students use Ritalin, Adderall, or Concerta, daily.                               

                                                                                                                                    ~Generation RX

The Rise of Therapeutic Ritalin:  Methylphenidate—which is structurally related to d-amphetamine—was synthesized in the 1940s and marketed for the first time as Ritalin in the 1960s.  In the 1970s, it was estimated that 150,000 children were taking “stimulant medication.”  In 1971, both amphetamine and methylphenidate were classified by the DEA as Schedule II substances.  By the 1980s, it was estimated that between 270,000 and 541,000 elementary school children were being prescribed methylphenidate.  However, by the mid 199os, the annual production and consumption of methylphenidate increased by 500%.  By 1995, 2.6 million Americans were taking Ritalin for “therapeutic” purposes, “the vast majority of who are children ages 5 through 12” (p.43).

Neurocognitive Enhancement: What Can We Do and What Should We Do?

Neurocognitive Enhancement: What Can We Do and What Should We Do?

Farah, Illes, et al.

Many are predicting that the twenty first century will be the century of neuroscience.  Humanity’s ability to alter its own brain function might well shape history as powerfully as the development of metallurgy in the Iron Age, mechanization in the Industrial Age, or genetics in the second half of the twentieth century. This possibility calls for an examination of the benefits and dangers of neuroscience-based technology, or neurotechnology, and consideration of whether, when, and how society might intervene to limit its use. (p. 30)

Examples: Brain-machine interfacing (see here and here), neurosurgery for psychiatric illnesses, transcranial magnetic stimulation (see here), and developments in psychopharmacology (see here).

“The psychopharmacopeia of the early twenty-first century encompasses both familiar, and in some cases highly effective, drugs, and a new generation of more selective drugs that target specific molecular events that underlie cognition and emotion” (p.30).

 

Dollars for Doctors

Given the important (and problematic) role played by pharmaceutical companies when it comes to the debate about lifestyle drugs, neuroenhancement, and non-therapeutic uses of medicine, it is important to pay attention to the questionable and morally suspicious relationship that has developed in this country between the companies who manufacture drugs and the doctos who prescribe them. See this ProPublica expose for some interesting data.

Flower on Lifestyle Drugs

“Lifestyle Drugs: Pharmacology and the Social Agenda”

Rod Flower

Question 1: 

What is a so-called “lifestyle drug”?  Is it merely “a medicine that is used to satisfy a non-health related goal or is used for treating problems that lie at the margins of health and well-being”? (Flower, p. 19)  Consider, for instance, sildenafil (erectile dysfunction), minoxidil (male pattern baldness), estrogen/progestin (birth control), and madfinil (jet lag).  Are these mere lifestyle drugs?  What about bupropion (nicotine withdrawal) or orlistat (obesity)?

Question 2: 

Who is the patient (or does it even make sense to talk about patients in this context)?  Usually, when we think about patients, they are sick or ill individuals receiving a therapy of some sort.  But are the people who take lifestyle drugs really sick?

As Flower asks, “When does a ‘need’ become an ‘illness’ or when does an ‘aspiration’ become a ‘legitimate’ therapeutic goal?” (p. 20) 

Before we can address this, we need to have a sense for what counts as an illness more generally.  But “illness” is a concept that similarly eludes definition. The same can be said about “health.”  While illness and health exist on a continuum, it is hard to specify when one ends and the other begins even if there may be paradigmatically clear cases of each.    For instance, the WHO defines health as “complete, physical, psychological, and social well being”—which is a standard that few will ever satisfy. 

Two Test Cases: (a) Baldness (with accompanying psychological problems), and (b) Social phobia (with accompanying psychological problems).

The worry:  “We risk turning natural expressions of human behavior into a “disease” that requires—or would benefit from—drug treatment” (Flower, p. 21).

This is sometimes called The Problem of Medicalization

As Flower points out, “with a growing understanding of the genetic contribution to diseases and other human characteristics, many more of mankind’s woes are likely to be perceived by the lay public as being beyond personal control and thus a legitimate target for drug therapy” (p.21).

Question 3:

Who should prescribe lifestyle drugs?  There are several factors fueling medicalization—e.g., internet access, disease support groups, patient consumerism, and direct advertising by pharmaceutical companies.  One problem with lifestyle drugs is that they tend to encourage self-diagnosis (which is a boon for the drug manufacturers)—which can put problematic pressure on medical doctors to prescribe the drugs (assuming, of course, that “patients” can’t just get the prescriptions filled on-line, thereby by-passing the medical professionals).    As Flower observes: “as the range of lifestyle drugs increases, we risk forcing physicians to act as social engineers or, at least, arbiters of the social norm” (p. 24).

Question 4:

Who should pay for lifestyle drugs? Needless to say, insurance providers are worried about the rise of lifestyle drugs, which negatively affect their bottom line.  As Flower points out, “there is legitimate concern that a system devised primarily to provide money for the treatment of illnesses should also be used to pay for drugs for which there is no compelling clinical argument” (p.25).  One move that governments and insurance providers will make to cut costs associated with lifestyle drugs is to limit or refuse reimbursement.  Rationining becomes especially problematic when money is spent on lifestyle drugs rather than more conventional medical treatments, etc. 

Question 5:

Who bears the risk?  How should we go about balancing the risk-reward equation when it comes to lifestyle drugs?  This is often difficult in the case of traditional therapeutic uses of medicine.  But, as Flower points out, it is even more difficult in the context of lifestyle drugs.  After all, “when ‘healthy’ people take drugs, who decides what level of side effects is acceptable, and who bears the costs of treating any ensuing iatrogenic disease? We are once again on treacherous ground, but a clue can be found in out attitudes to other ‘risky’ activities [e.g., highways and smoking]…the bottom line seems to be that if the intrinsic value of a product to the individual is sufficiently high, and the risk is voluntary, then most people will accept it willingly” (p.27).  But that people will accept the risk, descriptively speaking, doesn’t provide us with any evidence that they should accept it, normatively speaking.  Given what Flowers said earlier in the piece about medicalization and self-diagnosis/prescription, I think this is a bigger problem than he lets on.  As drug manufacturers bypass medical experts and pitch their products directly to “consumers,” it becomes increasingly likely that the consumers will under appreciate the risks (however detailed and hilarious the list of risks happens to be)

Question 6:

What can we expect moving forward?  Flowers starts by helpfully suggesting that there are not technically lifestyle drugs only lifestyles usages of drugs.  As he says, “drugs are just chemical substances that affect our bodies and our minds and that can be put to many different uses, some obviously therapeutic, some more recreational, and some directed towards satisfying other human aspirations” (p. 27).  It is nevertheless clear that the issue of lifestyle usages of drugs for enhancement rather than therapy is here to say.  Consider, for instance, the dystopian vision contained in Huxley’s prescient Brave New World.  After all, the “pharmacologic jewel in the crown of his imaginary society—and surely the ultimate lifestyle drug—Soma” was designed to give people a “holiday” from reality.  Are we on the verge of crossing the point of no return when it comes to the pax pharmacologica Huxley was warning us about?  

 

Neuroenhancement in the Classroom

Thanks to Bob for bringing this piece from CNN on Neuroenhancement to my attention.  Here are two of the more interesting bits from the article:

DeSantis' research found that 30% of students at the university have illegally used a stimulant, like the ADHD drugs Adderall or Ritalin. The numbers increase with upperclassmen. Half of all juniors and seniors have used the drugs, the study found, and 80% of upperclassmen in fraternities and sororities have taken them.

And here:

Students apparently don't see it that way. Another telling statistic from DeSantis' research at the University of Kentucky is how dangerous the students think these cognitive enhancing stimulants are. They say they see Adderall as slightly more dangerous than the soft drink Mountain Dew and nowhere near as dangerous as drinking beer and smoking.

So, there are two related issues at work here:  On the one hand, the use and potential abuse of stimulants as neuroenhancers appears to be widespread.  On the other hand, this situation is presumably partly being fueled by misinformation.

One of the students interviewed for the article identified Adderal as the cause of his improved academic performance:

He aced the test and got an A in the class. It's something Gabay has seen happen over and over since he started taking study drugs. He says he used to get Cs, but now with the help of Adderall, it's B's and A's.

Given how much can be at stake when it comes to your college grades, it's understandable that students would look for an edge.  However, it is taking "study drugs" morally appropriate or is it tantamount to cheating?  What do you think?

PHIL 261: Neuroethics

Welcome to the blog for PHIL 261: Neuroethics!  During the course of this semester, I will be posting course-related materials and thoughts on this blog in the hopes that students will join the conversational fray.  If you have something you'd specifically like to post and/or discuss, let me know and I will happily post something on your behalf (or, if you'd prefer, I will invite you to post it yourself!).  Thanks in advance for playing along.  I am excited about the course!  Hopefully, this blog will take on a life of its own as we progres through the material.