The power to examine and manipulate the brain offers the potential to change lives in profound and personal ways. As this potential becomes an ever-present reality, how will we make wise decisions about its use?
More than 150 neuroscientists, bioethicists, doctors of psychiatry and psychology, philosophers, and professors of law and public policy gathered in San Francisco on May 13 and 14, 2002 to discuss Neuroethics: Mapping the Field. The goal of the conference, organized by Stanford University and the University of California, San Francisco, and underwritten by the Dana Foundation, was to project the boundaries, deﬁne the issues, and raise the initial questions appropriate to a ﬁeld that probes the ethical implications of advances in brain science. Cerebrum presents a diverse selection of short excerpts from the conference’s panel discussions and major speeches, plus longer portions of the conference summary and concluding remarks on “The Future of Neuroethics.” The full proceedings are published by Dana Press and are available at www.dana.org.
Our New Promethean Gift
Chairman, The Dana Foundation, and columnist, The New York Times
Prometheus, you remember, was the god who was tortured for all eternity for bringing to man godlike powers... The subject of man’s Promethean presumption to create life, to interfere with what had been the exclusive domain of God or nature, is being ﬁercely debated today all around the world....The fear of playing God, as well as the countervailing hope of creating lifesaving life in the laboratory, roils the public reaction to science’s breakthroughs to our own new enlightenment. So, welcome to the ﬁrst symposium on one speciﬁc portion of that two-century growing concern, neuroethics: the examination of what is right and wrong, good and bad, about the treatment of, perfection of, or unwelcome invasion of, and worrisome manipulation of the human brain....
What’s the difference between ethics and morals? The Latin moralis was formed by Cicero as a rendering of the Greek ethicos, and the words have been used interchangeably ever since. But in their usage a distinction can be drawn. To me, moral has to do with right and wrong and ethics with good and bad. Now, what’s right is good and what’s wrong is bad, so there’s a lot of overlap. But I think of the difference this way: Moral implies conformity to long-established codes of conduct set primarily by religious authorities. Ethical involves more subtle questions of equity. The moralist asks, is it right by intrinsic standards? The ethicist asks, is it fair in the light of this society’s customs and in these times? Moral connotes standing ﬁrm; ethical, while still pretty stiff, can be said to swing a little.
Neuroethics in my lexicon is a distinct portion of bioethics, which is the consideration of good and bad consequences in medical practice and biological research. But the speciﬁc ethics of brain science hits home as no other research does in any other organ. It deals with our consciousness, our sense of self, and as such is central to our being. What distinguishes us from each other, beyond our looks? The answer: our personalities and behavior. And these are the characteristics that brain science will soon have the ability to change in signiﬁcant ways.
Let’s face it, one person’s liver is pretty much like another’s—giving rise to the expression, “What am I, chopped liver?” Our brains, on the contrary, give us our intelligence and integrity, our curiosity and compassion—and here’s the most mysterious one, our conscience. Our brain is the organ of individuality.
When we examine and manipulate the brain, unlike the liver or the pancreas— whether for research or treatment of disease, or for more sinister personal or political ends—when we do this, we change people’s lives in the most personal and powerful way. The misuse, or abuse, or failure to make the most of this power raises ethical challenges unique to neuroscience.
What’s more, neuroscientists have a built-in conﬂict of interest that sets them apart from all other ethicists. Everybody’s brain has a personal, selﬁsh interest in the study of the brain. It is the ultimate in self-dealing. Won’t a human brain tend to do what’s best for itself and take charge and take chances, plunging ahead to treat or improve the brain, as the brain might not do for the same body’s liver? In that regard, we know that our ethical sense arises from the brain. To stretch a point, one day imaging might ﬁnd right underneath the emotion of fear in the almond-shaped amygdala, a conglomeration of neurons acting as a conscience. The discoverer could shrink it, drug it, remove it, manipulate it in any which way, but how would this affect his or her decisions afterward? In possession of this power, how will we deﬁne and protect the integrity of our ability to judge morally and conduct ourselves ethically? ...
The people in this room are better equipped than most to take on the challenge of carving out a new territory for an old philosophical discipline.
Brain Science and the Self
ALBERT R. JONSEN, PH.D., CHAIR
Professor Emeritus of Ethics in Medicine, University of Washington
PATRICIA S. CHURCHLAND, PH.D.
Professor of Philosophy, University of California, San Diego
ANTONIO R. DAMASIO, M.D., PH.D.
Professor and Head of Neurology, University of Iowa Hospitals and Clinics
JONATHAN MORENO, PH.D.
Professor of Biomedical Ethics and Director, Center for Biomedical Ethics, University of Virginia
KENNETH F. SCHAFFNER, M.D., PH.D.
University Professor of Humanities, Department of Philosophy, George Washington University
WILLIAM MOBLEY, M.D., PH.D.
Professor and Chair, Department of Neurology and Neurological Sciences, Stanford University
Anthony Damasio began by talking about ethical behavior. He reminded us that ethical behavior was, in fact, a subset of all behaviors, one that is coextensive with emotion and that, in its expression, is the result of the interaction of several neural systems. Ethical behaviors are like other behaviors in that they make it possible for us to optimize our survival, our well-being. Because emotion is linked to ethical behavior, failed emotional behavior is the cause of failed ethical decisions and of potentially disastrous social consequences.
Patricia Churchland spoke to us of the self and of its capacities, especially decision-making. She provided us with a neural model for the self: indeed, a model for self-control in which various parts had distinct functions. Most attention was focused on the emulator; informed by perceived emotions and regulated by a conscience, the Churchland emulator judges the potential utility, efficacy, and safety of a series of possible actions before sending its outputs for processing into commands. She argued that there are systematic neurobiological differences between being in control and out of control, and that in time it will be possible to define these two states on the basis of well-characterized neurobiological properties. The implications, then, are that
- self-control is a fundamental and very understandable property of the brain, and
- that the brain is a dynamic machine whose actions are caused.
Kenneth Schaffner spoke of the sweeping versus creeping versions of reductionism and determinism. These models can be used to conceptualize neuroscience research and to consider the implications of their use for constructing theories of decision-making. The default position here, societally speaking, is self-determination and a belief that excluding conditions exonerate one from responsibility. Here the role of the emotions had to be taken more seriously, had to be in some way integrated with our current model.
Jonathan Moreno spoke of free will, as well, using as a deﬁnition that a free will is one that has been trained in the intelligent release of desire. He noted that modern American medicine assumes that the practice of free will must guide the physician/patient relationship and concluded that self-determination is thought to be a realistic moral standard.
The conclusions from the ﬁrst session, then, are these. First, that ethical and emotional behavior are linked. Second, emotion and reason may be part of a neurocontinuum. Third, that whatever one calls free will, the brain, as informed by a myriad of internal and external inﬂuences, operates to choose among the various desires or choices with which it is presented. Fourth, that at least in this sense, there is self-determination, or at the very least, the brain is consciously willing to take credit for this work that it does. Fifth, that in order to understand the brain, really understand it, we will need new paradigms. New data will create the need to throw out old models. In the end, our increased understanding will create, not inhibit, freedom. Less magic is not less interesting. Sixth, that neuroscience discovery will, in time, cover not just the spectrum that extends from behavior to circuits to cells and molecules, but eventually will extend into the domain of physics.
As conscious, and intelligent, and creative creatures living in a cultural environment, we humans have been able to shape the rules of ethics, to shape their codiﬁcation into law, to shape the application of the law into what we call justice.
*These summaries are excerpted from Dr. Mobley’s review of all the sessions at the close of the conference.
This is my hypothesis: ethics is part of a progression that includes all the non-conscious automated mechanisms, and that includes metabolic regulation, drives and motivations, emotions of diverse kinds, and feelings. But, again, do not worry that I am reducing ethics as we know it to a simple matter of evolution, or of gene transmission, or of gene expression, and of brain structures which, of course, permit all of these behaviors. As conscious, and intelligent, and creative creatures living in a cultural environment, we humans have been able to shape the rules of ethics, to shape their codification into law, to shape the application of the law into what we call justice—and we are still doing it. In fact, a lot of the ultimate purpose of a conference such as this is to begin discussing the way in which we may be continuing to do it as things get more complicated with the new results of science.
So, let me just close with a hypothesis, which is this: That we really would like to have some general understanding of the difference between someone who is operating with what we loosely might call free choice, and someone who is not. Let me change vocabulary slightly and say we want to understand the neural difference between someone who is, roughly speaking, in control and, roughly speaking, not in control...We don’t want to let the fact of causality in the brain entail that there is no responsibility, or that there is no difference between being in control and being out of control. I suspect that we will be able to find general and ultimately highly detailed ways of distinguishing between the in-control brain and the out-of-control brain.
We don’t want to let the fact of causality in the brain entail that there is no responsibility, or that there is no difference between being in control and being out of control.
Sweeping determinism claims worry philosophers and the philosophically inclined, but a mechanical determinism of a sweeping sort never had any legal relevance, so far as I know. Nobody ever brought somebody into court and said that they were mechanically determined by Newton’s Theory. But what does have legal bite regarding free will issues are what is called, in criminal law, “the excusing” and, in civil law, “invalidating” conditions. On this view, which I think I favor, attributing free will to an individual is the default position. But the presence of excusing conditions, some of which might be subtle and informed by neuroscience along the lines that we’ve heard from the first two speakers, would imply lack of free will. Excusing conditions include those forms of the lack of knowledge that make the action unintentional, lack of muscular control, subjection to gross forms of coercion by threats, and types of mental abnormality that are believed to render the agent incapable of choice or carrying out what he has chosen to do.
I realize that the ﬁeld of bioethics itself— and, I suspect, in its origins, the ﬁeld of neuroethics—is going to be very dependent upon the role of self-determination. And, in fact, it seems to me that modern bioethics, as compared to traditional medical ethics, has really placed a bet. The bet is, the wager is, that self-determination is a critical, if not the trump, value in physician-patient relations, and in decision making about ethical problems in health-care. Well, if self-determination turns out in some basic way to be a mistaken idea, then a modern bioethics has a problem. And it’s not a problem that modern bioethicists have worried about all that much—perhaps not as much as they should have. And as empirical evidence suggests increasingly that there are signiﬁcant cases in which even relatively well people may have impaired decision-making capacity, bioethics might have placed a rather dangerous wager.
Brain Science and Social Policy
BARBARA A. KOENIG, PH.D., CHAIR
Executive Director, Stanford University Center for Biomedical Ethics
HENRY GREELY, J.D.
Professor of Law, Stanford University
DANIEL L. SCHACTER, PH.D.
Professor and Chair, Department of Psychology, Harvard University
WILLIAM J. WINSLADE, PH.D.
Visiting Professor of Law and Associate Director, Graduate Programs at the University of Texas Medical Branch
Studying the brain offers the seductive promise that, by understanding brain function, we will gain the ability to make assessments about people, their motivations, their desires, their characteristics. The implications were discussed and debated in this session.
Memory is not perfect. Daniel Schacter reviewed the various causes of memory failure, providing examples of how these shortcomings are creating the desires for new forms of therapy, or for devising tests for determining when a memory is false. He presented recent neuroimaging ﬁndings showing that, in a small series of individuals, it was possible to ﬁnd a marker that correlated with false recognition. The question was raised as to whether this could be used to tell true from false memories, in a practical sense. The answer is that it is far too early to tell. The work is in its infancy, the ﬁndings are not yet robust. But it is possible that in time such tests could prove reliable.
William Winslade spoke of his work on brain-injured people and of the data showing that brain trauma is extremely common among death row inmates. There is very little appreciation within the legal system for the role that clinical neuroscience ought to play in the evaluation of such individuals. The argument was made that a much tighter link now needs to be made between neuroscientists and the legal system. Even now, brain science could give a clearer view of the extent of brain injury, but this power comes with concerns. Now they center on the interpretation of clinical data, which is a very reasonable concern. In the future, it may be possible to deﬁne to what extent a person was, or is, out of control, or indeed to predict a predisposition to criminal behavior. Would such a diagnosis result in incarceration or forced treatment?
Brain trauma is extremely common among death row inmates. There is very little appreciation within the legal system for the role that clinical neuroscience ought to play in the evaluation of such individuals.
Henry Greely spoke about the future of neuroethics, pointing to several ways in which it mirrored ELSI [the Human Genome Project’s program for addressing ethical, legal, and social implications]. The lessons learned from ELSI might well beneﬁt the ﬂedgling effort in neuroethics, apropos this point about the risks inherent in the ability to regulate neuroscience, even using current technology. Using neuroscience to predict outcomes was discussed. He also pointed to differences between genetics and neuroscience, noting that while we are not our genes, it was more difﬁcult to say we are not our brains. He concluded by noting the importance of building interdisciplinary teams to deﬁne and populate neuroethics.
Let the specifics of what neuroscientists have learned from the questions solve the real problems, of which there will be many, not the imaginary ones, of which the number is inﬁnite.
So, the conclusions from this session were, ﬁrst, that using the new technologies of neuroscience, it will be important to define “normal” and “abnormal.” These are condition sets, these are parameter sets, that will require new definitions. Second, that neuroscience is still a very young discipline. For most of the issues discussed, a great deal of additional research will be needed to bring neuroscience to the point where it can accurately predict behaviors or define characteristics. We have plenty of reasons for being humble about what we know. Third, it is not too early to begin to think about an effort to define how to evaluate the applicability of research claims, to set guidelines for how they would be used, and to translate them to practice. Next, that the standards we set for defining or predicting a characteristic of brain function will evolve with our increasing knowledge of the nervous system. Next, that neuroethics must engage all the communities represented at this meeting.
As a ﬁrst objective, I would recommend that one try, if possible, to develop a lexicon that everyone can understand. Commonly deﬁned terms would be very, very helpful. Next, it will be important to secure both public and private funding to build the discipline of neuroethics. Lastly, the fruits of neuroscience investigation should be the principal driver of the agenda for neuroethics. Let the speciﬁcs of what neuroscientists have learned from the questions solve the real problems, of which there will be many, not the imaginary ones, of which the number is inﬁnite.
DANIEL L. SCHACTER
In cases of memory pathology, overt memory disorder, if there is an effective treatment, to my mind at least, my simplistic cognitive neuroscience mind, the ethical issues are less pressing, because there we have a disorder that’s impairing the individual’s ability to function and that may eventually result in the loss of their entire sense of self. So, it seems that if we have an effective treatment, there is not a big issue about using it other than the usual kinds of questions that would arise about side effects and so forth. To my mind the question becomes rather different when we look at trying to depart from our baseline level of function.
WILLIAM J. WINSLADE
We may think that we can change people’s behavior by intervening. There’s always a danger of premature intervention or premature scientific claim; but my experience, at least in this area with traumatic brain injury, is that the law has been very slow to profit from the research and knowledge that are out there already and that I’m hoping will give us better insights in the future. But, there is a danger, and the danger in the law is to too quickly embrace reductionism. If somebody came forward with a convincing story and had all of the details of John’s brain injury [a hypothetical criminal discussed in the session] carefully pictured with the latest technology, there might be a tendency to too quickly dismiss his behavior as completely out of control and let him go, to the disadvantage of John and the rest of the community, because he might not be able to control his behavior...We would want to make sure that we remember that, however the brain is involved in behavior, even a damaged brain, a person’s behavior is affected by their earlier learning, by their genes, by their environment, by the circumstances— all kinds of things that the legal system needs to take into consideration.
Whether neuroscience predictions will turn out to be that determinative or not is unknown. We don’t know what the neuroscientists are going to come up with. My guess [is] based on the precedent of genetics... In a few cases there will be incredibly powerful inﬂuences that can be determined from neuroscience. In others there will be moderately powerful inﬂuences and in most there will be either weakly powerful inﬂuences or no inﬂuences at all. But, how much determinism turns out to be an issue in neuroscience depends heavily on what the science says... I am more than my genes. The genes are an important part of me, but they aren’t my essence; they aren’t my soul. When we shift that to the neuroscience area, though, I’m not quite so conﬁdent. Is my consciousness, is my brain, me? I’m tempted to think it is, but of course, I, like everybody in the room, come from a background that’s really emphasized intellectual efforts and intellectual endeavors, so we may be a biased audience for that.
No Brainer– Can We Cope with the Ethical Ramiﬁcations of New Knowledge of the Human Brain?
ARTHUR CAPLAN, PH.D.
Professor of Molecular and Cellular Engineering, Professor of Philosophy, and Chief, Division of Bioethics, University of Pennsylvania
Arthur Caplan advanced the hypothesis that we should try to improve our brains. He questioned whether there was really a difference between the goal of repairing a deficit and enhancing a normal state. We’re clearly doing the latter already. We modify the environment in which our children are raised and educated, in hopes that everyone can become extremely successful. Enhancing skills and abilities is a huge emphasis within our families. In fact, it is unlikely that you could find a parent in any culture that would not subscribe to this behavior. The concerns with enhancement are that it could be applied in ways that are unfair, unequal, unforgiving, and unnatural. Caplan advanced the idea that all of these points could be refuted, or at least dealt with, in a way that was consistent with current standards. The discussion given to the last point noted that we are not only the product of both cultural and biological evolution, we have been technologically modifying our biological heritage for some time. The issue for Caplan was not whether we should engage in enhancements. It was how we could best evaluate the possibilities for doing so, and how these activities would be regulated—presumably the terrain of neuroethics.
In 10 years—I’ll make a prediction—there will be a show that’s called, “My Brain Made Me Do It.” Someone will lie in a CAT scanner, it will work quickly, it will take a picture of your head, someone is going to say, “Did he do it/didn’t he do it?” Here’s a picture of his head. Some guy will come out and say, “I don’t know, his amygdala is kind of big. I think he did it.” And, that’s a way in which the culture will start to absorb information and knowledge about the human brain. So, when I’m about to mount a defense of the idea that some information in the brain sciences should be used to try and improve and enhance, I do have the [Jerry] Springer setting in mind, I do have a certain cross-section of humanity in the back of my mind about improvement and enhancement, but I don’t mean to be discriminatory— we can all use it. But we’re starting, if you will, from a culture that often gets its science, often gets its clinical applications, right out of the marketplace, right down in the grubby arena of exchange of ideas, entertainment, product marketing, and the rest of it.
Ethics and the Practice of Brain Science
BERNARD LO, M.D., CHAIR
Professor of Medicine, and Director, Program in Medical Ethics, University of California San Francisco
MARILYN S. ALBERT, PH.D.
Professor of Psychiatry and Neurology, Harvard Medical School, and Director, Gerontology Research Unit, Massachusetts General Hospital
STEVEN HYMAN, M.D.
Provost, Harvard University
ERIK PARENS, PH.D.
Associate for Philosophical Studies, The Hastings Center
PAUL ROOT WOLPE, PH.D.
Senior Faculty Associate, Center for Bioethics, University of Pennsylvania
Steven Hyman spoke of neuropharmacology and the evidence that drugs can evoke long-term changes in the structure and function of neurons. The concerns raised by these data are to some extent balanced by concerns for what happens to neuronal function as a result of not treating brain disorders. For the right patients, drugs work, they work well, and they ought to be used. Illustrating his points, he discussed the use of Ritalin for ADHD, and pointed to the need for better diagnostic measures, better treatments, more treatments, and physicians more skilled in managing these treatments.
Marilyn Albert spoke of the issues facing patients with Alzheimer’s disease and their families. The current ethical issues center on the utility, or lack thereof, of genetic testing, the inability of patients to give informed consent, and the need for more powerful methods for predicting the disorder. This will change when effective therapies come on line; then, the important focus will be on pre-symptomatic diagnosis, so the treatment can begin before there are irreversible changes in function.
Erik Parens returned to the issue of enhancement and argued that the treatment/enhancement distinction might be useful for articulating a basic package of care, for critiquing social practice, and for affirming natural variation. A great deal of discussion focused on this topic. Some viewed it as useful or desirable that enhancements not be used: that is, that there was value in working through a disability. Others came down strongly on the side that enhancements, if available, should normally be used. Steven Hyman reminded us that psychiatry dealt with this issue with respect to antidepressant medications, and that the benefits of medical psychotherapeutics were not just the ability to treat these conditions more effectively, but the ability actually to change the biological model that we thought of when we thought of the word “depression.” Enhancement changed our view of the biology.
Paul Wolpe sketched a very aggressive view of the future that technology would play in neurobiology. The use of such technologies will clearly require a new way of thinking about the interaction of technology and biology, and how new interventions should be evaluated and regulated.
So, in conclusion, for this session, first, it is vital that we develop new and effective treatments for neurological and psychiatric disorders. Second, moving treatments to the clinic will bring with it new and difficult issues for neuroethics: Who can be tested? With what protections for privacy? And who can give consent? Whether or not the individual has the right to deny such treatments will also emerge as an issue. Third, neuroethics could help establish how best to move new treatments to the clinic, and to regulate their use. Fourth, the treatment/enhancement distinction may be useful for defining certain aspects of care. As our ability to intervene in brain function increases, it will become increasingly difficult to distinguish the two. We already practice enhancements and will continue to do so. Neuroethics can play a role in defining under what conditions this practice is harmful to the individual and/or to the society. Last, that the fruits of neuroscience investigation be the principal driver of the agenda for neuroethics.
We have to ask ourselves: Is there a moral or ethical difference between, say, lowering cholesterol levels and altering neurotransmitter levels?
We have to ask how drugs differ from ordinary experience in physically changing the brain. That doesn’t mean there aren’t differences, but the question is more sophisticated than it might seem at ﬁrst blush. And, we have to ask something else. Since experience also remodels the brain, we have to ask how having an untreated mental illness, or even a moderate impairment, affects the developing brain or the adult brain, and how it affects real-life outcomes. Because, before we at least clinically think—worry—as we should about the permanent effects or long-lived effects of drugs on synaptic architecture and on lived experience, we also had better think about what life is like for some kids without such treatment...It’s very important to recognize that we often treat, as a society, psychotropic drugs differently from other drugs. We talk about the need not just to treat illness, but to prevent it or to intervene early, which often means in children—except when it comes to psychotropic drugs. We have to ask ourselves: Is there a moral or ethical difference between, say, lowering cholesterol levels and altering neurotransmitter levels?
It seems pretty clear that people are desperate to prevent a decline in decision-making, but when they know the disease [Alzheimer’s] has progressed very far, the likelihood of returning to their normal self has gone. And, to me, that’s often in a way similar to somebody who has lived to be very old, is actually cognitively normal, but has undergone enormous physical decline. You might offer them a treatment that would make them a little bit better, and they might actually refuse it. I think many of us know such circumstances, and we believe that individuals who are in that position, who have complete cognitive capacity, have the right to choose not to be a tiny bit better than they might be, because they feel as if even that state isn’t good enough for them.
What we really are becoming is some kind of cyborg, some kind of post-human, in the sense that for the ﬁrst time in history we really are going to incorporate our synthetic technologies into the very physiology of our being.
Imagine that there’s a pill that could reduce discriminatory attitudes towards dark-skinned people, people with more melanin than the dominant group in this country. And everybody agrees discrimination is hurtful to people who are discriminated against; they suffer as a result of it. Now, if people are suffering, why not give this pill, the color-blindness pill? The fear is that in giving the pill we become complicit with the unjust norm, the norm being that particular skin pigment is preferable. For those without the pill, or those who decide to go off the pill, the unjust norm remains in place; nothing has changed...Then the question is, well, but should anybody’s well-being be sacriﬁced on the altar of social justice?... It seems to me that it’s really important never to be willing to sacriﬁce somebody else’s well-being on any altar. But, it also seems to me really important to remember that, again, our different means of achieving ends—that is, the end of discrimination—make a difference. They express different understandings of who we are.
PAUL ROOT WOLPE
We have learned how to hack into the Web-ware between our ears in the same way that we’ve learned how to hack into other systems and change the patterns of communication over the Internet and other ways. We’ve learned to enhance the inherently slow perceptions of our brains...I think that the point of all this is that what we really are becoming is some kind of cyborg, some kind of post-human, in the sense that for the ﬁrst time in history we really are going to incorporate our synthetic technologies into the very physiology of our being—with consequences that I don’t think are trivial and that can’t necessarily be captured in the sort of single-issue way we’ve been approaching it up until now...We need to ask the sort of broader question of what is the next step of evolution—using that word in its sort of common sense rather than its technical sense—how is it that as a species we want to direct ourselves, and towards what goals, as we begin to incorporate our bionics into our bodies?...We can’t ask the question of ethics once the science is already out of the barn.
Are There Things We’d Rather Not Know?
DONALD KENNEDY, PH.D.
President Emeritus, Stanford University, and Editor-in-Chief, Science magazine
Donald Kennedy spoke of his long-term love affair with science and with policy. He reminded us of the enormous behavioral capacity of animals and of how many of the characteristics we like to think of as human are, in fact, represented in animals. On the issue of free will, he was less sanguine about deﬁning it than about documenting well the speciﬁc neurological phenotypes that could be used to excuse aberrant behaviors. He welcomed the continuing engagement that surrounds the therapeutic use of genetic manipulation, and, ﬁnally, placed primary responsibility for ethical decision-making in the hands of neuroscience investigators.
Culture acted on the brain, and the brain, of course, in growing in capacity and size, acted upon culture to create more of it.
There’s a broader issue, and...that is whether our interventions into transmitter biochemistry aren’t interfering with something called our nature...To find a natural human, I suppose you’d have to strip away the rest of human culture. I think if you do that, you get back to a human with a cranial capacity of about 500 cubic centimeters, around 2 million years ago...So you’ve now got a long history of interaction between the human brain and culture. To be told that when human culture reached some particular level, natural selection stopped is a terrible misunderstanding. Natural selection went right on. In fact, what culture did was to give natural selection a kick-start...As a result, you have the brain growing faster in allometric terms than any other organ probably in the history of vertebrae evolution. Culture acted on the brain, and the brain, of course, in growing in capacity and size, acted upon culture to create more of it. You have explosive positive feedback, and that positive feedback has made us what we are. We’ve been tampering with our brains all the time. Now, there may very well be things we don’t want to do to our brains, even things we shouldn’t do to our brains. But to appeal to a natural state as justiﬁcation for eschewing that kind of intervention seems to me to ignore some terribly basic biology.
Brain Science and Public Discourse
JUDY ILES, PH.D., CHAIR
Senior Research Scholar, Stanford University Center for Biomedical Ethics
COLIN BLAKEMORE, PH.D., SC.D.
Professor of Physiology and Director, Oxford Centre for Cognitive Neuroscience, University of Oxford, UK
MICHAEL S. GAZZANIGA, PH.D.
Professor and Director, Program in Cognitive Neurosciences, Dartmouth College;
Member, President’s Council on Bioethics
Science Writer, The Chicago Tribune
Colin Blakemore pointed to the efforts in the United Kingdom to educate the public with respect to science, and how, in spite of these efforts, public conﬁdence was rocked by a series of problems, AIDS and Mad Cow disease among them. The media linked these problems to the scientists and blamed them—quite unfairly, obviously. The crisis has motivated a new attempt to engage the public. Now, in a general and genuine discourse, it is not the scientists talking to the public, it is scientists and the public talking together.
Ron Kotulak talked of his experience as a science reporter. He noted an important role for the media in bringing science to the public. It is possible to do this responsibly, and for scientists and reporters to work together as full partners. Indeed, scientists need to learn to work more effectively with the media to communicate the process of science and its beneﬁts.
Michael Gazzaniga discussed his experiences on the President’s Council on Bioethics panel. His recommendations for successful service on such panels included: accept resistance as the norm; take time to educate your colleagues; and, finally, communicate the joy of science to your colleagues and to the public.
It is also important to emphasize that science is not written in stone, that it is a constantly changing process of discovery.
In conclusion, for this session, we have the responsibility to educate the public and to be educated by them. We have to do it well. This must be a dialogue, and it’s a dialogue that has to begin immediately, driven by science, driven by the things we know about science, and the joy we have in it.
I think [the] idea of debates between scientists in public, or between scientists and those with a different interpretation of scientific evidence, is a very good one, and I think one has to recognize that there are various agendas, subtexts, involved in this move towards dialog. One is to give the public a genuine sense of possession or ownership of science... Wherever your money comes from, whether it comes directly from public funds, or from charitable foundations, or even from industry, in the end, it has come from the public purse, from people spending money in order for scientists to do their work...But another subtext is genuinely to tap the common sense of ordinary people in arriving at ethical decisions about how science should be applied. It’s all too easy to become detached, either by your own inflated view of the importance of your work or your commercial interest in it, not to take account of how just ordinary people are going to react to it. But the third is to increase public knowledge, not just of scientific facts, the Trivial Pursuit type facts of science, but of how science works.
Too often the public views a new scientiﬁc announcement as a ﬁnal fact, only to be confused and frustrated when another report contradicts it... When I ﬁrst started covering science (and I’ve been doing this for over 30 years), it was ﬁne; you could write a daily story and people would accept what it was because that was all that was available. Today we’re inundated with information coming from all over. I think it’s part of our job to try to make sense out of it, to try to put it in some kind of perspective, and I think it’s part of the job of the scientiﬁc community to help us do that. But it is also important to emphasize that science is not written in stone, that it is a constantly changing process of discovery.
What is wrong with science in its representation to the public? And do we need to change that? ...I think where the failures come is that the public doesn’t know three things. First of all, they don’t appreciate the deep, moving experience of the scientist actually discovering something and knowing a secret of nature. That feeling all the scientists in this room know, they respect it deeply, they understand it, and it generates the entire energy structure of their life. Secondly, what most of the public doesn’t know is scientists are ruthlessly conservative. They are the people who absolutely cannot abide sloppiness in a report, in an experiment. They are looking as one scientist is talking to the other, basically the other scientist is always looking at that person saying how is he wrong?...So to realize that scientists are not the people out there trying to push the baby over the cliff, that, in fact, they are the people that keep a brake on runaway crazy ideas in our culture. To communicate that notion is vastly important, and that is a difference between science and scientists. As we all know, scientists can be too excited about their work to put perspective on it. But science comes along very slowly and very conservatively, and aggressively tries to keep things straight.
What It Means to “Map” the Field of Neuroethics
ALBERT R. JONSEN, PH.D.
Professor Emeritus of Ethics in Medicine, University of Washington
We have used the metaphor of mapping as a theme for the conference. I think, in the last day and a half, we have mapped at three different levels. The first level at which we began some cartography was actually the geological level. Since we had a nice little earthquake last night—welcome to my city, San Francisco. There’s a tectonic level of ideas; the ﬁrst session was at that tectonic level. The questions of determinism and reductionism, which are perpetually part of philosophical reﬂection, return again and again, and because of that they are insoluble questions. Yet, they occasionally seem to have great salience for our ways of understanding each other. One clear place where they may have salience was actually mentioned yesterday: that is, the way in which we think about free will. Obviously it has implications for the way in which we deal with the criminal justice system. But in general, there’s this tectonic level of questions, the fundamental questions that continue to be asked and rethought and reﬁned in terms of the kinds of new questions that arise.
There’s a second level, which we did not actually discuss much. There were occasional references to it, but no explicit discussion. I’d call that the geographical level (as distinguished from the geological level). The geographical level is the hills and the mountains and the valleys and the water, and all of that. The reason to map a geography is to learn how to get around in it. Here, the questions at the geographical level, I think, are largely epistemological questions—that is, how do we think about these issues? What do we do to assure ourselves that certain assertions are reliable when they come from quite different epistemic sources? When philosophers talk, they make assertions. When scientists talk, they make assertions. Those assertions come out of signiﬁcantly different sources and ways of thinking of what they’re doing...
The questions of determinism and reductionism, which are perpetually part of philosophical reﬂection, return again and again, and because of that they are insoluble questions. Yet, they occasionally seem to have great salience for our ways of understanding each other.
The ﬁnal level of mapping is the mapping of the locale. By that, I mean the populated regions, the kind of maps that you get when you come as a visitor to San Francisco and rent a car, which gives you the streets. I think that the mapping of those regions—of the locales—began when we started to talk about the particular issues that have certain boundaries around them. Discussions of problems in research with human subjects. Discussions about legal accountability in the criminal justice system. Discussions about enhancement and treatment. These are cases. They are particular locales that have relative boundaries around them, so that you have a phenomenon that you can look at, where people can say: Well, this is a case about deaf children. And we know what deaf children are, we think. But we’re not sure what they are, when it comes to how they live within their community, and so we want to ﬁnd out. We want to see what that experience is. We add to experience by experiment, by data analysis, by debate, by communication, by the formulation of policy.
These particular issues of mapping the locale, mapping the populated regions, are probably what will go ahead most rapidly and precipitously, because these are the things that interest us. And here is where we probably have to start thinking in terms of what the relationships are between these various parts of the map. That is, when do these questions that seem to be questions of the locale or the terrain have to be thought of also in terms of the geology, of the deeper questions? Here, we have some micro-questions—questions of the locale—such as research, or legal accountability. And there may be some macro questions, such as the nature of free will....
The Socratic dialogue, which is obviously an artiﬁcial and literary device, seems to me to be a very genuine representation of the nature of ethical discourse. That is, it is people talking and arguing with each other. Ethics really begins with conversation, and it moves on from conversation as people see that there are disputes involved, and begin to ﬁnd out why the disputes are of the sort that they are—whether it’s because of commitments to a deep geological kind of question, or whether it’s a matter of facts that need to be clariﬁed. I think that what has happened in this conference is a perfect example of that. The long discussion periods, where many people could enter in, were extremely valuable and created a kind of a Socratic dialogue. I think we have begun something that may, I hope, turn into something rich and valuable.
Mapping the Future
ZACH W. HALL, PH.D., CONFERENCE CHAIR
Senior Associate Dean of Research, Keck School of Medicine, University of Southern California, and past director of the National Institute of Neurological Disorders and Stroke
I want to begin talking about the future of neuroethics by saying that this meeting has changed my own sense of what neuroethics is and what we should do. At the very least, the meeting has given me a new metaphor for thinking about neuroethics. I believe that we do have the ability to make choices, as Dr. Moreno pointed out. If we do not, what are we doing here? Making choices is what we as human beings do. We have a sense of right and wrong and make choices about what to do.
We also realize, however, that our ability to make ethical choices—and the range of those choices—are constrained by both biology and culture. One problem to grapple with, particularly at a meeting like this, is that some of us have stronger sensitivities and capacities for thinking about these issues. There is a range within our society of people who are concerned with or able to make the kinds of distinctions we are discussing here.
In thinking about how we make these distinctions, I was taken with the comments of one participant who pointed out that habits are what people do largely without conscious choice—automatically, without thinking. But to do something new, we must ﬁrst bring it into consciousness…..
I ﬁnd this a useful metaphor. What we do in making ethical choices is bring matters into consciousness, where we can think about them, examine them, be aware of all the factors at play. I like Patricia Churchland’s idea of the emulator, playing out the different scenarios—a process that can be unconscious but is most effective when we think about various scenarios that follow if we make one or another choice. Our reason lets us do this. But my own view—in agreement, perhaps, with Antonio Damasio—is that in the end, when our intellect has played out all the choices, we listen to how we feel about the various possibilities; we listen to our gut. Bringing matters into consciousness seems to me at the heart of making ethical decisions. Indeed, it is amusing to wonder why we have consciousness at all. What is its evolutionary value? Perhaps that great expansion of the cortex that Don Kennedy referred to in primate evolution was related to an increasing sense of consciousness, and perhaps the selective evolutionary advantage of consciousness is control, enabling us to make better decisions, and, at the same time, to own those decisions.
All this is fascinating from a personal point of view, but also a useful metaphor for thinking about neuroethics. Maybe the most useful thing that we can do as a group to advance neuroethics is to try to bring into consciousness, the consciousness of society, what we are doing in brain research and what its possible consequences are. Then it is society’s job to decide how it feels about those consequences, to engage in the kind of clash of values we have played out on a small scale here—particularly this morning with discussions of some contentious social issues that stir up strong feelings. If the job of neuroethics is to bring into the consciousness of our society matters related to research on the brain, how do we go about it?
Bringing matters into consciousness seems to me at the heart of making ethical decisions. Indeed, it is amusing to wonder why we have consciousness at all. What is its evolutionary value?
First, we need a scholarly discipline of neuroethics. Thinking in this new ﬁeld must be based on scholarship, with rich connections to philosophy, psychology, law, and other ﬁelds. We need people who are professionally committed to thinking about these problems, who will develop with their colleagues a language and traditions that are held and understood in common, allowing important questions to be thrashed out through reﬂection, inquiry, scholarship, and learned discussion. They must be familiar both with the nuances of contemporary neuroscience and with philosophical thinking. Let’s realize that we don’t start from zero when we think about ethical problems; they have engaged the greatest minds for over a thousand years. The scholarly discipline of neuroethics should become an arena in which the best methods of philosophical analysis—that is, rigorous, disciplined thinking—are brought to bear on these questions.
The future of this new ﬁeld will be the students and professionals that it attracts. I am pleased to see at this meeting young people with backgrounds in neuroscience, ethics, and philosophy who are keenly interested in what we are discussing. One young woman introduced herself to me by saying: I want to be the next Patricia Churchland. My response was: Right on: that’s just what we need.
Neuroethics is not for ethicists or neuroprofessionals alone; it must involve politicians, religious leaders, public policy experts and even columnists from leading newspapers. The questions are too important to be left to the experts; experts are often wrong.
Our second goal should be to foster the discussion of neuroethical problems by professionals in medicine and biology. Physicians and scientists will be at the front lines in dealing with these questions because they are carrying out the procedures, prescribing the drugs, and doing the experiments. Much of the power will lie in their hands. We’ve seen, over the last 25 years or so, a growing sensitivity to issues such as informed consent and patients’ rights. These issues are most germane and urgent for the brain because of the potentially irreversible changes that we can make and because essential human characteristics are at stake. Education, heightening the sensitivity of neurosurgeons, psychiatrists, and neuroscientists, is going to be tremendously important. We will look to our professional societies—the Society for Neuroscience, the neurology societies, psychiatric associations, and the neurosurgical societies—to lead in providing expert opinion on specialized problems that arise.
That brings me to the third and most important point. Although neuroethics scholarship and the professional concern of scientists and physicians are crucial, if we stop there, we will have failed.
Neuroethics is not for ethicists or neuroprofessionals alone; it must involve politicians, religious leaders, public policy experts and even columnists from leading newspapers. The questions are too important to be left to the experts; experts are often wrong. So the challenge is involving these groups in thinking proactively about issues. What happens is that a matter suddenly arises, emotions run high, and the discussion is dominated by the contingencies and quick reﬂexive thoughts of the moment.
What is needed is a mechanism to identify these issues before they arise, to discuss them beforehand, and to marshal our best thought and expertise around speciﬁc issues.
The issues remain to be deﬁned, although we’ve heard several suggestions. William Winslade pointed to the pivotal role of brain injury in legal matters, something not yet addressed in a thoughtful, informed way. Another issue was regulation of surgical procedures on the brain. Surgical procedures are not regulated by the Food and Drug Administration. As regards the brain, what is and what is not? The challenge in all these cases, absent an emergency, is how to get busy, overburdened people to sit down and talk….
We heard this morning that there is not unanimity among us about many practical issues we face. Each of us has prejudices and preconceptions, which will be magniﬁed when a wider audience is engaged. Questions of values, questions that reﬂect fundamental decisions about values in our society, will take time to sort out. How should we regard treatments of the brain that make us happier, smarter, and more personable? If we have a pill to make us feel better, or perform better, we will take it because it stimulates our reward centers, directly or indirectly, by feeding our self esteem. Such treatments will be aimed at basic biological circuits in the brain. In a society in which the availability of self-improvement treatments depends on the capital markets, one sees the potential exploitation of these deep biological needs, with resulting loss of the very control that we seek… These situations are not susceptible of rational debate; they have to do with the reluctance of governments to interfere with markets or with people’s freedoms. The same dynamic affects harmful effects of things we want to do, particularly from addictions. We have ambivalent feelings about these and cannot control their use.
Identifying harm is a particular responsibility in neuroethics because of long-term effects on the brain.
Our society remains perplexed about how to handle things we want but that may harm us. This dilemma is at the core of the desire for things that make us feel good but may have deleterious side effects, or, in the case of heroin or nicotine, actually do harm.
Given that many of the important issues will be ones that informed, concerned people disagree on, what is the responsibility of neuroethics? Perhaps the ﬁrst thing is to focus on identifying harm. We don’t say you shouldn’t take a pill just because you shouldn’t, because it’s unnatural or against evolution; we identify potential sources of harm from its use.
Look at tobacco… The 1960s Surgeon General’s report showing the ill effects of smoking was a turning point in reducing nicotine use, because it said, look, this is bad for you.
Identifying harm is a particular responsibility in neuroethics because of long-term effects on the brain. We’ve heard at this meeting about many agents that act on the brain most effectively by making long-term alterations. Those are things we must be careful of.
The other major responsibility that seems clear to me is the protection of the weak and disabled and of children and the identiﬁcation of situations in which vulnerable populations are exploited. The discussion of deaf children yesterday was a fascinating example of some ways that values swirl around these issues. We do not know what to do with issues about how children are treated or how to deal with people who are disabled with psychiatric illness or addictions.
I’d like to end by saying that it seems to me a chief danger is half-knowledge, thinking we know best, we know what is right. I think again of the prefrontal lobotomies and psychosurgeries, examples that give us a large dose of humility and remind us of our need to engage the larger society.
We heard an amazing quotation from Dr. Moreno yesterday to the effect that the physician knows what is best. In our more modern version it is the scientist who often thinks he knows what is best, if others will only listen. Here we must heed Colin Blakemore by engaging society—not to educate them or guide them, but to exchange views as fellow citizens together, learning from them and from ourselves about the often contradictory values that are the foundation of our society.