James Giordano

Working towards a new psychiatry - neuroscience, technology and the DSM-5

This Editorial introduces the thematic series on Toward a New Psychiatry: Philosophical and Ethical Issues in Classification, Diagnosis and Care http://www.biomedcentral.com/series/newpsychiatry.

Transcranial magnetic stimulation, deep brain stimulation and personal identity: ethical questions, and neuroethical approaches for medical practice.

Neurotechnology provides means to engage micro- and macrostructural networks of the brain to both mitigate the manifestations of several neurological and psychiatric disorders, and alter cognition and motoric activity. Such capacity also generates questions of how these interventions may affect personal identity. This paper discusses the ethical implications regarding changes to personal identity that arise from the therapeutic use of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS) technologies. In addition, we raise the question of whether changes in personal identity, as a side effect of these interventions, are ethically acceptable and whether such alterations of personality foster patients’ sense of well-being and autonomy. First, we provide a series of case vignettes that afford an overview of the ways that various neurological interventions can affect personal identity. Second, we offer a brief working definition of personal identity in order to delineate an ethical framework that we deem necessary for the responsible use of neurostimulation technologies. In so doing, we argue that neurostimulation therapy, as a doctoring act, should be directed, and adherent to goals of restoring and/or preserving patients’ personal identity. To this end, we offer an ethical framework that we believe enables sound decisions about the right and good use of TMS and DBS.

Neuroethics: Interacting “Traditions” as a Viable Meta-Ethics

as there is currently no majority position in the moral philosophy community about the empirical hallmarks of a particular ethical theory, the possibility of testing both metaethical and normative theories, and fundamental issues of metaethics, like the contrast between realism and anti-realism. In particular, we lack a position about these issues that is considered to be justified by most moral philosophers, according to a common standard of justification. In its absence, there will be no agreement among philosophers about the consequences of the forthcoming advances in cognitive and affective neuroscience, and empirical science will be stopped from effectively contributing to the development of moral thought in the way that Levy envisions.

The Interfluence of Neuroscience, Neuroethics, and Legal and Social Issues: The Need for (N)ELSI

until recently. But upstream research may be a way for social science or ethics investigations to have more policy-relevant impact. The National Science Foundation-funded Center for Nanotechnology in Society at Arizona State University, for example, emphasizes the integration of social science, humanities, and bioethics research methods and questions in the earliest stages of nanotech research and development (Fisher 2005). In this way, the societal end of nanotechnology development is also the beginning of the scientific process, and is built into the nature of the final product itself. This sort of integration depends on the willingness of scientists to collaborate with nonscientists, but funding mechanisms can provide incentives to scientists to participate in such collaborations. In neuroscience there is already goodwill toward research on societal impact, given the work of the US Neuroethics Society and public engagement activity funders such as the Dana Center. How should ELSI-L Neuroscience be managed and structured? I don’t see any obvious reason why there should be one centralized mechanism, such as the ELSI HGP, to oversee this program of research. To ensure that there is interaction across the four streams of research, and to support collaborations between scientists and nonscientists, I like the idea of multidisciplinary centers, in which principal investigators build a research group and agenda around each stream, ensuring a balance of methodological and theoretical orientations. A center model does not guarantee interdisciplinarity or good outcomes, but here too we can learn from the genomics precedent. Genomics centers, at least in the United Kingdom, have not delivered the high level of research and impact that was hoped for. This is due in part to the nature of the genomics beast, which has had far less societal impact than was expected when the genomics centers were set up. There have also been the perennial problems of translating social science-speak into policy-speak, and building productive, mutually beneficial, multidisciplinary collaborations. These are not easy tasks, but they can be fruitfully addressed now that we know so much more about the pitfalls of the collaborative process. My own vision for ELSI-L Neuroscience is that it integrate the political and the public health dimensions of neuroscience within a global field, thereby radically growing the scope of neuroethics research and interest. The ELSI-L agenda should include investigating the possibilities that neuroscience creates for tackling pernicious social and ethical problems across diverse national contexts and social conditions.

Neuroscience, Neurotechnology, and National Security: The Need for Preparedness and an Ethics of Responsible Action

We concur with Jonathan Marks (2010) that brain science can and will continue to be employed in military, and other national defense/security applications. We also concur that recent misdirection of science and medicine under the rubric of national security has raised serious concerns about (1) the uses and misuses of these techniques and technologies and (2) the level of transparency maintained by government research laboratories, if not overall initiatives. We believe that these concerns are valid and must be considered, addressed, and responded to; however, we also maintain that an intellectual, practical, and ethical commitment to brain science is critical to national security. Perhaps at the core of any such discussion is the need to consider both America’s current status as a superpower, and the importance of remaining in this position in the future. Once this affirmation is made, it then becomes critical to assess and analyze why, how, and with what means this role has been achieved and can be sustained. While a complete discussion of these variables is beyond the scope of this paper, of note to our commentary is that the superpower status of the United States is certainly attributable, at least in part, to its technologic, scientific, and economic capabilities, and to collaborative sharing of these capabilities with its allies (Baxter 1946). We assert that it is important to maintain our science and technology (S&T) initiatives through research, development, testing, and evaluation (RDTE), so as to remain in a position of global political superiority. Moreover, we believe that American superpower status is also built upon a set of moral values that are grounded in a reverence for humanity, beneficence, and respect for autonomy. Thus, we hold that any and all enterprises that fall within a rubric of asserting and sustaining

Considering Enhancement (and/or Treatment): On the Need to Regard Contingency and Develop Dialectic Evaluation—A Commentary on Singh and Kelleher

The transitory nature of these withdrawal experiences, existing, as they would, amid a time of emotional tumult for most young people, means they are not accounted for in Singh and Kelleher’s consideration of long-term effects on brain or self; nor do they introduce something entirely new such that these considerations could easily be accounted for in the category addressing young adults’ understanding of self, as this very understanding, even in the best of times, is evolving. Erring on the side of caution with regard to neuroenhancements in young people calls for an even higher standard than with the therapeutic uses of these same drugs. For this reason, attention to the effects of sudden discontinuation of the drug ought also to be considered and unless they are shown to be mild or nonexistent, the drugs causing the effects should be, at minimum, strongly discouraged for enhancement purposes, regardless of either the young person’s or the relevant guardians’ willingness to accept the risk. REFERENCES

Real-time functional magnetic resonance imaging-brain-computer interfacing in the assessment and treatment of psychopathy : potential and challenges

This chapter focuses on the engagement of real-time functional magnetic resonance imaging-brain-computer interfacing (rtfMRI-BCI) in the treatment of psychopathy and some of the more pertinent ethico-legal and social issues fostered by such use of this neurotechnological approach. To this end, we first provide an overview of the nature of psychopathy. Second, we pose the premise that given the paucity – if not frank absence – of effective psychopharmacological treatment(s) or rehabilitation strategies presently available for psychopathy, it becomes important to examine the present state of neurotechnologies that might be used to effect potential benefit in the treatment of this disorder and focus this examination upon the possible utility of rtfMRI-brain-computer interface technology. Third, we present an overview of those tools that are currently used to determine and diagnose psychopathy and discuss their limitations. Finally, we address the major ethical questions and issues arising from the use of this technology to modify behavior in individuals with psychopathic traits

Culture, subjectivity, and the ethics of patient-centered pain care

Even the most scientifically reductionist view of the individual reveals that we are complex systems nested within complex systems. These interactions within and among systems are based and depend on numerous variables of our (internal and external) environment(s). If we define ethics as a system of moral decision making, then it becomes clear that these decisions ultimately affect the situation(s) of managing our activities and relationships with others in our environment (in essence, our being in the world). Given that ecology literally means “a study or system of wisdom and reasoning about the interrelation of organisms in their environment or place of inhabitance,” Owen Flanagans description of ethics as “human ecology” takes on considerable relevance and importance.

Unusual Claims, Normative Process: On the Use and Stringency of the Scientific Method

Do unusual claims require extraordinary proof? A scientific claim is evaluated through application of the scientific method. This involves experimentation (most rigorously in comparison to some form of control) and/or observation. Analyses and descriptions can be quantitative or qualitative, but adherence to stringent criteria to ensure validity of method and outcomes is essential. Claims that have been evaluated by this method are then disseminated through publication and/or presentation so as to be independently tested by other scientists. If such tests support the original claim, then, following a sufficient but indeterminate number of successful replications, the claim and any accompanying hypotheses and theories may be added to the scientific lexicon. If such tests fail to support the original claim, it is questioned and rejected (usually following a lesser number of replication attempts than is required to accept or sustain such claims). These results are commonly considered as ‘proof’ among the non-scientific, lay public. However, this is a misnomer. The process of discarding and/or accepting scientific claims is one of convergence upon ‘a truth’ that is subject to change as a consequence of scientific knowledge itself. Therefore, scientific claims and the truths they seek are always tangential. Unlike a mathematical proof, scientific claims and accompanying hypotheses and theoretical bases are always subject to scrutiny, challenge and revision, based upon both ongoing evaluation of the claim, and intellectual understanding of science and nature, at large. This is true for unusual claims as well as the more mundane. To suggest that something further needs to be applied to scrutinize an unusual claim is to misunderstand the principles of the scientific process, and scientific philosophy. It is of course a truism that all important or groundbreaking claims are by definition ‘unusual’. The elegance of the scientific process is that it addresses and evaluates all claims and discoveries identically. The process itself is progressive as Joshua Roebke claims ‘... science is ... an unending courtship, flirting ever closer with the absolute truth it desires though may never attain’ [2]. The scientific method, though rigorous, is not perfect. But, as Roebke notes, may be ‘... the best tool humans have for discerning facts of the world ...’ and ‘its utility, despite its limitations, earns it our trust’. The process of peer review is only a first step toward solidifying such trust and participating in that courtship. In this issue, such attention may be directed to somewhat ‘unusual’ scientific claims regarding outcomes and mechanisms of homeopathic treatments in which it is claimed that medicinal value may be found in solutions that do not contain the active ingredient. This seems contrary to the established theoretical understanding of pharmacobiology. However, the scientific approach is not to reject a claim simply because it seems implausible or unorthodox. Rather, the scientific approach is to test the claim. Historically, there have been numerous examples of scientific claims that were considered implausible, unorthodox, if not impossible based upon the epistemology of the time and/or culture, but were subsequently validated (e.g. heliocentricism, germ theory, etc.). In hindsight, we recognize that it was our understanding of both the claim and the natural world that was flawed. In this issue of FORSCHENDE KOMPLEMENTARMEDIZIN, Pathak and colleagues seem to have made an implausible claim – that an oral solution with none of the putatively active molecule present can significantly impact the course of hepatic neoplastic disease in a mouse model [3]. They have tested this hypothesis in their laboratories and maintain that there is evidence to support their claim. They have described the conditions under which tests of this hypothesis were performed and have submitted their findings to peer review pursuant to publication in this journal. This is the scientific process.

Hormesis mediates dose-sensitive shifts in macrophage activation patterns

&NA; The activation or polarization of macrophages to pro‐ or anti‐inflammatory states evolved as an adaptation to protect against a spectrum of biological threats. Such an adaptation engages pro‐oxidative mechanisms and enables macrophages to neutralize and kill threatening organisms (e.g., viruses, bacteria, mold), limit cancerous growths, and enhance recovery and repair processes. The present study demonstrates that (1) many diverse pharmacological, chemical and physical agents can mediate a dose/concentration‐dependent shift between pro‐ and anti‐inflammatory activation states, and (2) these shifts in activation states display biphasic dose‐response relationships that are characteristic of hormesis. This study also reveals that preconditioning—another form of hormesis—similarly mediates tissue protection by the polarization of macrophages, but in this case, towards an anti‐inflammatory phenotype. This assessment supports the generalizability and significance of hormesis in biology, medicine, and public health and further extends it to encompass the hormetic activation of macrophages. Graphical abstract Figure. No caption available.