Ethical, Legal, and Social Issues in Brain Research
Sandro Gindro, Emilio Mordini
Istituto Psicoanalitico per le Ricerche Sociali, Rome, Italy
Brain Research is a rapidly expanding field of science. Neuroscience in general is one of the areas of contemporary biology characterised by a growing number of important achievements not the least of which being the ordinary treatment of psychiatric and neurological disorders. This promises a transformation of many current cultural, philosophical, ethical and legal standards. A number of noteworthy articles have recently been published dealing with these issues, and a pan-European research project on " Ethical, Legal, and Social Aspects of Brain Research" has been launched by the European Commission.
The advancement of brain research and neuroscience, the development of pharmaceutical research, the increasingly important use of new technologies in psychiatry and neurology are changing the traditional scenario of these disciplines [1**]. The advancement of knowledge implies also a growth in the number and complexity of the problems. It is now clear that there is a need to identify specific ethical, legal, and social standards to be adopted in brain research, neuroscience and their clinical applications [2**]. In 1997 the European Commission launched a research project on "Ethical, Legal, and Social Aspects of Brain Research" (BRAIN ELSA). With this project a number of diverse and prestigious organizations and institutions explore the ethical, legal and social implications and impact of brain research. This article intends to present the state of ethical and scientific debate in the domain of BRAIN ELSA.
The debate on the nature of psychiatry has been particularly lively during the last few years [3,4,5]. The main issue at stake is the relationship between different disciplines that deal with the human mind. As Bloch [6**] states: "We could celebrate achievements in neurobiology, psychopharmacology, psychology theory, epidemiology and social psychiatry, and much more beside. Indeed, it would not be a matter of hubris to claim that we have learned more in this century than during any other period in the history of psychiatry. But, this progress, I contend, has come at a cost: a tendency for the profession to fragment." Fragmentation is thus the key word to understand the impact that research is having on psychiatry as an editorial published in the May 1997 American Journal of Psychiatry  also reminds us. Fragmentation might be overcome, at least in perspective, considering that mind and brain are nothing but the two sides of the same coin. A plea for "embraining" the mind has been sustained by Seli and Shapiro : "Now it is time to pool resources and knowledge together to approach, treat, and apply scientific techniques to the analysis of brain disorders as a product of brain structure and function interacting with personal and social experience". But is pooling resources and knowledge sufficient to found a new psychiatric paradigm? Bloch [6**] does not share this opinion. He proposes to substitute the icons of the couch and the brain with a three-legged stool, the three legs being science, art, and ethics. The debate on future psychiatry has important consequences in psychiatric ethics [9,10]. Indeed, the traditional psychiatric ethics remain important but run the risk of becoming obsolete .
In his chapter in the Encyclopedia of Applied Ethics, Hattab [12**] gives an impressive picture of psychiatric ethics in the age of brain research. Hattab's main argument concerns the confusion between the brain as an organ, and the brain as a concept, which he calls: the anatomic brain and the metaphoric brain. He argues that "when speaking of brain research and functions we have the tendency to confuse these two brains". In another article  he extensively describes the two basic fantasies that, in his opinion, underlie brain research: the "total control fantasy", according to which all human behaviours and thoughts could be understood and controlled, and the "total freedom fantasy", according to which mental functions would be totally free and the brain would be only the tool to express these functions. From a different perspective, Riffer  seems to share Hattab's view; she argues that what matters in psychiatry is the personal, subjective experience, while the mere fact that the disease affects the brain is irrelevant.
Brain morphological research is one of the most important areas in current neuroscience. The main question, 100 years after Freud's project for a scientific psychology, remains whether the complexity of the brain will ever be understandable, or if there are some irreducible elements in mental functions that cannot be explained in biological terms . The issue has some ethical implications, indeed brain morphological research can be ethically justified only if it is scientifically sound. Cunningham Owens [16*] describes and discusses the main techniques to obtain morphological information on the brain. His conclusions are categorical: "Morphometric and functional brain research is now an integral part of the most concentrated effort in a century to understand some of the most distressing illnesses to which man can fall victim. It will undoubtedly expand. The only ones with anything to fear from this work are those who, for ideological reasons, cannot accept its basic premises".
Yet some warnings have been raised about the risk that brain morphological research may become a tool to handle social and cultural conflicts, by trying to ground them on neurobiology [17*]. The debate was first provoked by the hypothesis of the sexual brain , according to which sexual orientation is linked to the brain's organisation. This kind of hypothesis, that in principle should preserve cultural minorities from stigmatisation and social blame, is ethically risky. Schüklenk [19*] warns us about the risk that studies on genetics of sexual orientation may mask a new kind of homophobia. This leads us to the wide subject of the ethics of research on the neurobiological basis of human behaviour. Parens  argues that "behavioural genetics is helping us to learn that any rich account of human behaviour must, at a minimum, recognise the nonlinear and dynamic interactions within and between our internal and external environment". Parens' view seems to be supported by Raine and colleagues  that suggest that positron emission tomography (PET) may be able to identify criminals. PET brain imaging was conducted on 41 murderers pleading not guilty by reason of insanity and 41 age- and sex-matched controls. Murderers were characterised by a specific PET pattern and authors conclude that their findings show "a network of abnormal cortical and subcortical brain processes that may predispose to violence". The issue of human responsibility vis-à-vis neuroscience has been widely debated [22*]. On the basis of brain imaging techniques, Spence  argues that conscious free will is incompatible with the evidence of neuroscience. Glover , giving an impressive account of the main theories on human responsibilities, ends up pointing out that the only possible position is "soft-determinism". Likewise Gindro [25**] advocates the use of the Kantian als ob (as if) in neuroscience. Gindro claims that reseachers should simultaneously think of humans as if they were ruled by determinism, and as if they were free agents. What Gindro suggests is that the problem cannot be solved by linear and rational processes, but that it needs a non-Aristotelian approach. The issue has important consequences for bioethics in general, as emphasised by Gaylin : "A too rigid defence of autonomy is dangerous not just because it preemts other values such as justice and virtue, but also because it interferes with more sophisticated concepts of freedom."
Another important issue raised by brain morphological research concerns the organisation of laboratories specifically devoted to the brain, called "brain banks". They first appeared in the 1970's and in 1992 a Concerted Action of the European Community, coordinated by F. F. Cruz-Sànchez, brought together several European Brain Banks in order to standardise protocols and to collect data . Brain banks make human nervous tissue available to researchers "for the advancement of knowledge particularly in those disorders that have a low incidence and/or that can not show well defined clusters". Brain banks are also a vital tool for human cDNA libraries. Brain banks pose some puzzling problems and may have an important ethical, legal and social impact [28**]. The main issue is that of brain donation, which implies both the donor's informed consent, and sensitising the society to organ donation for scientific purposes. Other issues concern confidentiality, ownership of biological materials, risks of economic exploitation.
Any kind of brain physical manipulation poses a basic question: "Where is the border between preservation and alteration of brain identity?" [29*]. The entry on psychosurgery of the Encyclopedia of Applied Ethics, written by Missa [30**], gives a comprehensive overview of the problem, furnishing both an historical perspective and an accurate description of the present scenario. Neurosurgery is one of the medical disciplines that has been significantly affected by new technologies . Of course, some of these technologies are controversial and others are still experimental, thus posing a broad range of ethical problems . In particular, current neurosurgery raises anew the issue of acceptable indications for functional neurosurgery and psychosurgery. Considerations of autonomy can justify some kinds of functional neurosurgery as various capacities and activities that define autonomy materially depend on complex neural processes that occur in the human brain [33**]. New developments in neurosurgery also confirm that there are no simple relations between the extension of the lesion of the brain tissue involved and the patient's personality. Also early warnings about personality transfer in neurografting have proven to be without foundation. It makes clear that the evaluation of personal identity cannot only rely on philosophical arguments but on neurophysiological findings as well [29*, 34]. In neurotransplantation some reasons for ethical concern regard the usage of human embryonic and foetal material, in particular when this material comes from voluntary aborted foetuses . The use of animal cells, and human genetically modified cells, which excrete missing neurotransmitters or neurotrophic factors, is still scientifically controversial , and may create some new clinical and ethical problems [37*]. The need for specific criteria to be adopted in laboratory use of brain tissue has been recently addressed by Burd and coll. [38**].
Dementing disorders have several ethical implications. Three main issues are at stake. First, dementia poses some basic questions about personal identity. Post  argues that "A new ethics of dementia care will not accept the postulate of some ethicists that rationality and memory are the features of the person that give rise to moral standing and protection". Even the main arguments raised by Dresser [40, 41] against the usage of advanced directives in dementia concern the relationship between changes in personality, memory and human personhood: "substantial memory loss and other psychological changes may produce a new person, whose connection to the earlier one could be less strong than that between you and me". Should one be entitled to make decisions for a future individual so different from the present self [42, 43*, 44]?
Another group of ethical problems is related to genetic testing for Alzheimer Disease. In March 1997, JAMA published the Consensus Statement of the US National Study Group on Ethics, Genetics and Alzheimer Disease [45**]. The document intended to answer to the following questions: "1. For which patients and for what purposes is it clinically and ethically appropriate to introduce genetic testing for AD?" "2. How should demand for such testing be answered?" "3. What standard should govern the disclosure of test results in light of potential discrimination?". A consensus was reached on the use of genetic testing in the 3 dominant early-onset forms of AD, while the National Study Group suggests that the search for the APOE genotype should be excluded for asymptomatic persons because of the high risk of social discrimination. The document ends advocating "further educational efforts" to respond to public concern.
Eventually another set of ethical issues will regard dementia drug development [46**]. A new generation of antidementia drugs is developing and it promises to pose a number of ethical, legal, and social problems, including consent to clinical trials, and potential conflict of interest between researchers, pharmaceutical companies, and AD Advocacy Organisations.
The philosophical and ethical relevance of psychiatric classification continues to be in the limelight of the debate [2**]. The question is whether a description of mental disturbances can ever be neutral and value-free [47,48]. It has been claimed that new technologies promise to give a more "objective" description of mental diseases [49, 50*], but this is likely to be a naive perspective. In psychiatry one should adopt the point of view of modern physics according to which no observer can avoid interfering with the observed object and, therefore, that there is no neutral observation. Fulford compares descriptivist models (fact-before-value model) with nondescriptivist models (fact-plus-value models) [51**]. Fulford's argument is that "Mental health is at the soft end of scientific medicine. A fact-plus-value model repolarises this view. Technological medicine is seen to be operating in a relatively simplified area of practice, one in which questions of value, although arising in principle, can be ignored (i.e., because the relevant values are widely agreed upon). In fact, of course, mental health to the extent that its organ is the brain, is more complex scientifically (empirically and conceptually) than, say, cardiology. A fact-plus-value view shows that it is also more complex ethically".
Some interesting papers on ethical implications of psychopharmacotherapy have been published recently [52**, 53, 54*, 55]. All authors are intrigued by the potential for "cosmetic" treatment of new psychiatric medications, namely the use of drugs as mood enhancers and to improve behaviour. The case of Methylphenidate (Ritalin), largely used in the US to treat Attention Deficit Hyperactivity Disorder (ADHD), is taken as a paradigm: "the ADHD diagnosis was seen as a diagnostic cover, albeit inaccurate, for the use of stimulants in a range of behavioural and performance problems in children" .
Advances in brain research may significantly affect future psychotherapies [56, 57, 58]. From a therapeutic point of view it is now clear that the continued applicability of psychodynamic approaches does not exclude the use of modern pharmacology as well as the new understanding of psychosocial factors. The interest in the psychosocial network is increasing, as shown by the concept of "Unconscious Social Drive" introduced by Stoller  and the description of the "Social Unconscious" made by Gindro . According to Gindro, the human's unconscious is made up of three fundamental criteria: Instinct, Individual Unconscious, Social Unconscious. What Gindro suggests is that every human being is born into a prefabricated environment endowed with a complex catalogue of messages and stimuli which will condition him. The individual reacts to conditioning, attempting, in turn, to condition the group through continuous interaction. The newborn perceives fantasies of the mother, the words of the father, but also the emotional coloring of the social group. All these elements contribute to the formation of that constellation of values in the midst of which every human being defines himself. The concept of the social unconscious has important consequence for ethics, as Riker [61*] has also recently emphasised.
Many other ethical issues in psychotherapy have been raised in the last period. To cite a few: the ethics of suggestion and manipulative techniques [62, 63*], the ethics of therapeutic responsibility [64**], the ethics of attention , which, according to Lipson and Lipson, investigate the psychological processes that are the prerequisite of moral action. Eventually a new interesting chapter of ethics in psychotherapy will regard the use of new technologies, such as the internet [66, 67], CD-Rom , and telemedicine [69*].
We are almost at the end of the "Decade of the Brain". It is thus a time to measure our progress. The enthusiasm connected to new findings in neuroscience perhaps needs to be tempered. Even if the tumultuous growing of knowledge cannot be denied, it is clear that there are more things in heaven and earth than are dreamt in our philosophy. The ancient Socratic motto "I only know that I know nothing" is always valid, in particular speaking of the human mind. Yet new findings are already sufficient to address a number of new, puzzling, ethical, legal and social problems and it is easy to predict that the next decade will be the decade of the ethics of brain research. Indeed, the BRAIN ELSA project is an indicator of how quickly the subject is developing. The administration of the project is entrusted to a project management group chaired by S. Gindro (IT) and of which also take part: R. Bartlett (UK), H. Baumgartner (AU), S. Bloch (AUS), G. Boer (NL), R. Bracalenti (IT), J. Carbajosa (ES), F.F. Cruz-Sànchez (ES), S.De Risio (IT), M. Di Giannantonio (IT), K.W.M. Fulford (UK), F. Gerstenbrand (AU), P. Gruenberg (USA), H.Helmchen (GE), E. Mordini (IT), J. Vollmann (GE).
This work was supported by a grant from the European Commission - DG XII - ELSA (contract: BIOTECH2 B104 CT97 2264).
AD - alzheimer diseases
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