Walter Glannon

Stimulating brains, altering minds

Deep-brain stimulation has been used to treat advanced Parkinson disease and other neurological and psychiatric disorders that have not responded to other treatments. While deep-brain stimulation can modulate overactive or underactive regions of the brain and thereby improve motor function, it can also cause changes in a patient’s thought and personality. This paper discusses the trade-offs between the physiological benefit of this technique and the potential psychological harm.

Psychopharmacology and memory

Psychotropic and other drugs can alter brain mechanisms regulating the formation, storage, and retrieval of different types of memory. These include “off label” uses of existing drugs and new drugs designed specifically to target the neural bases of memory. This paper discusses the use of beta-adrenergic antagonists to prevent or erase non-conscious pathological emotional memories in the amygdala. It also discusses the use of novel psychopharmacological agents to enhance long term semantic and short term working memory by altering storage and retrieval mechanisms in the hippocampus and prefrontal cortex. Although intervention in the brain to alter memory as therapy or enhancement holds considerable promise, the long term effects of experimental drugs on the brain and memory are not known. More studies are needed to adequately assess the potential benefits and risks of these interventions.

Phase I oncology trials: why the therapeutic misconception will not go away

In many cases, the “therapeutic misconception” may be an unavoidable part of the imperfect process of recruitment and consent in medical research Paul Appelbaum, Loren Roth, and Charles Lidz coined the term “therapeutic misconception” in 1982.1 They described it as the misconception that participating in research is the same as receiving individualised treatment from a physician. It referred to the research subject’s failure to appreciate that the aim of research is to obtain scientific knowledge, and that any benefit to the subject is a by-product of that knowledge. More recent studies by Appelbaum and Lidz have shown that this phenomenon is just as pervasive now as it was twenty four years ago.2 The problem pertains not to any duty of care for researchers but to participants’ unfounded belief in the therapeutic potential of research.3 It is especially acute in phase I oncology trials, which aim to test the toxicity and highest tolerable dose of anticancer drugs. To remedy this situation, many have argued that both clinicians and researchers need to do more in explaining to subjects the differences between experimental research and standard care. Clinicians and researchers recruiting potential subjects for research must present information about the expected risks and benefits of participation in research in a more realistic and straightforward way.4 In one recent examination of consent forms for phase I oncology trials, Sam Horng et al found that, in the section on “benefit”, only one of 272 forms stated that the subjects were expected to benefit. They also found that 11 consent forms (four per cent) stated clearly that subjects would not benefit, 25 forms (nine per cent) communicated uncertainty about benefit, and 5 forms (two per cent) said nothing about the chance of benefit. Interestingly, 139 forms (51 per cent) alluded to the …

Should all living donors be treated equally

Recently, Matas et al. described a protocol to accept as potential donors altruistic strangers who offer to donate a kidney to any patient on the waiting list. The selection of donors would be the same as the process they use for living, emotionally related donors, except that the full work-up would have to be done at their institution and would include a detailed psychosocial evaluation. In this article, we present a case that raised the question of whether the medical standards for nonemotionally related donors should be the same as the standards for emotionally related donors. We argue that we must distinguish between the altruistic donation by a stranger and the voluntary donation by an emotionally related individual. We argue that voluntary donations have a degree of moral obligation based on intimacy and that intimacy allows, but does not require, that these donors take on slightly additional risk.

Indentity, Prudential Concern, and Extended Lives

Recent advances in human genetics suggest that it may become possible to genetically manipulate telomerase and embryonic stem cells to alter the mechanisms of aging and extend the human life span. But a life span significantly longer than the present norm would be undesirable because it would severely weaken the connections between past- and future-oriented mental states and turn the psychological grounds for personal identity and prudential concern for our future selves. In addition, the collective effects of longer lives might lower the quality of life for all people. These two problems provide reasons against genetic manipulation of cells to alter the length of the human life span.

OUR BRAINS ARE NOT US

Many neuroscientists have claimed that our minds are just a function of and thus reducible to our brains. I challenge neuroreductionism by arguing that the mind emerges from and is shaped by interaction among the brain, body, and environment. The mind is not located in the brain but is distributed among these three entities. I then explore the implications of the distributed mind for neuroethics.

Neuromodulation, Agency and Autonomy

Neuromodulation consists in altering brain activity to restore mental and physical functions in individuals with neuropsychiatric disorders and brain and spinal cord injuries. This can be achieved by delivering electrical stimulation that excites or inhibits neural tissue, by using electrical signals in the brain to move computer cursors or robotic arms, or by displaying brain activity to subjects who regulate that activity by their own responses to it. As enabling prostheses, deep-brain stimulation and brain–computer interfaces (BCIs) are forms of extended embodiment that become integrated into the individual’s conception of himself as an autonomous agent. In BCIs and neurofeedback, the success or failure of the techniques depends on the interaction between the learner and the trainer. The restoration of agency and autonomy through neuromodulation thus involves neurophysiological, psychological and social factors.

Underestimating the risk in living kidney donation.

4Yet recent data suggest that the long-term risk in living kidney donation and the personal cost may be higher than previously thought. This risk may become more significant given the increasing incidence of hypertension and especially diabetes in both developed and developing countries, where it is the most common cause of end-stage renal disease. 5 This raises ethical questions about what constitutes permissible risk in transplantation, whether the benefits of living kidney donation clearly outweigh any costs to the donor, and the extent to which transplant surgeons and the medical community should promote LDKT. 6 More generally, LDKT raises the question of how to weigh the physician’s duty to do no harm to the patient against patients’ autonomous choice to put themselves at some risk of harm in order to benefit others. These questions have been raised mainly with respect to the surgical transplant procedure itself but seldom with respect to the period beyond the surgical procedure of procuring the organ for transplantation. The risks associated with living donor liver lobe transplantation are greater than those associated with living donor kidney transplantation. 7

Beyond consent in research. Revisiting vulnerability in deep brain stimulation for psychiatric disorders.

Vulnerability is an important criterion to assess the ethical justification of the inclusion of participants in research trials. Currently, vulnerability is often understood as an attribute inherent to a participant by nature of a diagnosed condition. Accordingly, a common ethical concern relates to the participants decisionmaking capacity and ability to provide free and informed consent. We propose an expanded view of vulnerability that moves beyond a focus on consent and the intrinsic attributes of participants. We offer specific suggestions for how relational aspects and the dynamic features of vulnerability could be more fully captured in current discussions and research practices.

Psychopathy and responsibility

Some philosophers have argued that the psychopath serves as the ultimate test of the limits of moral responsibility. They hold that the psychopath lacks a deep knowledge of right and wrong, and that Kant’s ethics arguably offers the most plausible account of this moral knowledge. On this view, the psychopath’s lack of moral understanding is due to a cognitive failure involving practical reason. I argue that the deep knowledge of right and wrong consists of emotional and volitional components in addition to a cognitive one. Hence it is mistaken to claim that the psychopath’s moral deficiency is due solely to a cognitive failure, or that his lack of the deep knowledge of right and wrong can be explained entirely in terms of a defect of practical reason. I refer to empirical research to show that the Kantian model of practical reason does not provide a satisfactory account of responsibility of the psychopath in particular or of moral agents in general. On the basis of both philosophical and empirical considerations, I argue that the psychopath is at least partly responsible for his behaviour.