Neuroethics & Law Blog

Epigenetics, Existentialism, and Mind-Body Dualism (Khan)

On my previous post regarding the ethical implications of epigenetics research, Aileen Kennedy provided a thoughtful comment on how this might relate to the concept of mind-body dualism. Instead of writing a short reply to Ms. Kennedy, I decided to devote a full blog post to how our developing understanding of epigenetics might alter how we think about the relationship between biology and identity.

Among modern philosophers, Descartes stands out for his elucidation of the Platonic concept of mind-body dualism. Descartes theorized that the body was simply like a machine and that what truly defined one's existence or true identity was the immaterial mind (recall his famous dictum: “cogito ergo sum—I think, therefore I am”) which controls the body. In other words, the body is simply a coalescence of flesh (like a mindless Golem) that has little to do with defining one's essence outside of purely material or aesthetic considerations.

Of course modern medicine and neuroscience have rejected this Cartesian notion that the mind is purely immaterial and not connected to any physical tissue. However, in its stead modern medicine has established its own mind-body dualism of neural tissue being the repository of our individual identity and the rest of our body being purely functionary but not defining our essence. Indeed, neuroscience has located different areas of the brain (e.g., the amygdala as the seat of emotion and social learning and the pre-frontal cortex for self-control and goal-setting) that can grossly said to be related to one's personality or identity. For instance, if someone has their frontal lobe damaged by physical trauma or prenatal exposure to alcohol, doctors can predict that person will exhibit problems with impulse controls among other issues.

Further, we can see this mind-body dualism manifested in a variety of ways, such as private cryogenics providers offering to freeze simply one's head but not the rest of the body (because the brain is all one really needs to preserve the immortality of one's existence) with the hope that this head can be reattached to a donor body in the future. We also see in it in modern bioethical regulations. Consider the UK's ban on allowing human-animal chimera embryos to develop past 14 days. http://news.bbc.co.uk/2/hi/health/6524883.stm Why 14 days you might ask? The reason is that shortly after 14 days in human embryos the primitive streak (beginning of spinal and brain tissue) starts to form and the differentiation of pluripotent stem cells into neural crest cells begins. The ethical argument is that before “generic” stem cells (which are actually unique in terms of their DNA) differentiate into neural cells, there is no potential for the putative organism to develop any individuality. Ergo, human individuality (identity) stems from neural tissue--other human (body/corporeal) tissue is irrelevant in this regard.

However, there has always been anecdotal evidence that non-neural cells can also exhibit “memory” or fundamental markers of one's unique identity. There are numerous case reports of heart transplant recipient all of a sudden being endowed with the artistic skills or peculiar dietary preferences of their deceased organ donors. In other words, the existential or lived experiences of the heart donor seems to have been imprinted upon their non-neural tissue and appears to be “talking to” to the cells in its new host body. Before one relegates this concept of “cellular memory” to sensationalist new-age hucksterism that one might find on daytime television (yes, I'm calling you out Oprah for giving credibility to “The Secret”) consider that Dr. Gary Schwartz of University of Arizona has documented 70 cases where transplant recipients have inherited fundamental personality traits of their donors (http://www.dailymail.co.uk/health/article-381589/The-art-transplant.html#ixzz13mkpSZg9).

While these case reports are not definitive proof that cellular memory exists, the concept that individual cells outside of our brain are indeed imprinted with our life's experiences seems more plausible with the epigenetics providing a demonstrable and logical mechanism of how this might occur.

Will this concept of non-neural tissue storing important information about one's individual, existential identity change normative considerations relating to organ donation, embryonic stem cell research, cry, etc? I honestly do not know, but I think it is interesting to pose this question and see what others think.(Khan)

 

Exploring Human Enhancement Symposium

EXPLORING HUMAN ENHANCEMENT: A SYMPOSIUM
at The Center for Values in Medicine, Science, and Technology
The University of Texas at Dallas
April 8-9, 2011
Renaissance Hotel, Richardson Texas

Details here.

Putting money in the pot: does neurological evidence support legalizing marijuana? (L. Syd M Johnson)

Marijuana is the most widely used illicit substance in the United States. On the ballot in California in the upcoming election is Proposition 19, an initiative to legalize marijuana. The state-initiated proposal, the Regulate, Control and Tax Cannabis Act of 2010, would legalize personal possession of up to one ounce, and regulate and tax the growing and sale of  cannabis. One of the key goals of the initiative is taxation, with large amounts of revenue expected to flow into California’s empty coffers. The ability to tax and regulate what is currently an illegal drug has long been a chief argument advanced in favor of legalizing marijuana. An assortment of strange bedfellows have rallied on both sides of the debate in California: some stoners oppose the law as too restrictive, while anti-drug groups oppose it for not being restrictive enough. Republican and Democratic politicians, district attorneys, and police chiefs support it, citing, among other things, the savings to law enforcement, the legal system, and the penal system associated with decriminalizing marijuana use and possession. Current polls show the voters of California are about evenly divided on the matter.

An additional claim frequently offered in support of legalization is that marijuana is no more dangerous than tobacco and alcohol, both of which are legal. Is that claim true? The short-term effects of marijuana use — memory impairment, stimulation of appetite, disruption of psychomotor behavior, etc. — are well-known, and of course, comical, if the career of Cheech & Chong is any indication. Needless to say, there are reasonable concerns about public safety  should decriminalization result in larger numbers of marijuana users driving or working while impaired. There is conflicting evidence on the long-term effects of cannabis use. In animal studies, long-term cannabinoid administration has been shown to be neurotoxic, resulting in decreases in neuronal volume, and neuronal and synaptic density. Less is known about the effects of long-term exposure in humans, and only a handful of brain imaging studies have been conducted, with inconsistent findings. An Australian MRI study, for example, revealed reduced hippocampal and amygdala volumes in long-term, heavy users with no history of polydrug use. Users performed significantly worse than controls on verbal learning (Yucel et al, Arch Gen Psychiatry. 2008;65(6):694-701). Matochik et al employed voxel-based morphometry and found differences in grey and white matter tissue density between heavy marijuana users and non-users (Matochik et al Drug and Alcohol Dependence 2005;77:23-30). Still other studies have shown both neurotoxic and neuroprotective effects of cannabis use.

The evidence for the safety (or danger) of recreational marijuana use, thus far, is inconclusive, and supports neither legalizing nor criminalizing cannabis. The matter  warrants further study, particularly if decriminalizing becomes a more widespread phenomenon. As cash-strapped states look for creative solutions to their fiscal problems, it could be that legalizing marijuana will increasingly be viewed not as a public scourge but as a potential revenue stream — like the taxation of alcohol and tobacco. Should that happen, concern will shift to practical control of the predictable social and public health consequences of legal marijuana use.

Some Hauser Retrenching

The science section of today's NYT has a piece on the ongoing investigation into Marc Hauser's research conduct, though details are still few and far between.  Interestingly, the piece suggests that some critics are retrenching their harshest allegations.  [Ed: Here's the link.]

Two Talks at Harvard Law School

I'll be giving a couple of talks at Harvard Law School next week.  As usual, blog readers in attendance are encouraged to introduce themselves.

 

Talk #1 (Open to the Public)

 

Title: "The Experiential Future of the Law"

Time: Monday, November 1, 5-7pm 

Place: Hauser Hall, room 105, on the Harvard Law School Campus

Sponsor: Harvard University Petrie-Flom Center's Health Law Policy and Bioethics Workshop 
 

Link to download draft article here.

 

Talk #2

 

Title: "Freedom of Memory"

Time: Tuesday, November 2, Noon-1 pm 

Place: Pound Hall, room 107, on the Harvard Law School Campus
Sponsors: (1) Student Association for Law and the Mind Sciences and (2) Ethics, Law, and Biotechnology student organization  

Links to download articles here and here.

Epigenetics Research, “The Culture of Poverty,” and “The Bell Curve” (Khan)

The New York Times recently ran an article (http://www.nytimes.com/2010/10/18/us/18poverty.html) on how scholars are rediscovering the “culture of poverty,” the idea that persistent poverty among certain demographic groups stem not from longstanding economic disadvantages or structural discrimination, but rather from a culture that predisposes its members to economic failure. One does not have to read the commentary following this article to recognize that this is a hot-button issue in academia and why many scholars are ambivalent about this topic. On the one hand, it is easy to see how this theory can be manipulated into “blaming the poor” for their situation and justifying social policies that neglect investment of government resources (e.g., education, housing, healthcare, welfare, etc) in poorer communities since it is their culture, not their socio-economic context that needs to change. On the other hand, if researchers have identified certain cultural practices (e.g., not valuing education) that are maladaptive and inimical to the interest of any particular group, one can understand how they would not want political sensitivities to impede efforts and policies that may improve the socio-economic conditions of any particular demographic.

So what does the “culture of poverty” have to do with epigenetics? I'll get to that. First, a brief background on epigenetics—it is the field of inquiry that looks at inherited changes in gene expressions that are caused by mechanisms other than changes in the DNA code (genetics). So for instance, researchers have identified how a variety of environmental exposures, from chemical exposures to being a holocaust survivor can imprint DNA with epigenetic markers that can modulate gene expression like a light dimmer switch. This in itself may not seem extraordinary as nature (genetics) and nurture (environment) have long been understood to affect one's individual phenotype (physical expression of underlying genetic traits). However, what is novel about recent understanding of epigenetics marks is that they are “sticky” and can last for several generations. The implication of this is that some harmful exposures (like toxins or being a victim of violent oppression) which your grandparents experienced, might still be affecting you on an epigenetic level even if you never experienced such exposures.

Last year, when I gave a talk to a legal academic audience on the implications of epigenetics research, I referenced studies that demonstrated that maternal nutrition could have a dramatic impact on childhood physical and neural development (http://www.ajcn.org/cgi/content/abstract/88/3/789) including a positive correlation with higher maternal fish intake and higher child IQ scores (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2807%2960277-3/abstract). As an aside, I mentioned that such studies effectively debunk the notorious “The Bell Curve” theory of Charles Murray and Richard Herrnstein that differential IQ scores among demographic groups are explicitly attributable to genetics (and that implicitly nothing can be done about the so-called “achievement gap” because genetics are largely immutable). If IQ scores can be altered by maternal nutrition (among other environmental variables), this renders untenable Murray and Herrnstein's contention that IQ scores are primarily based on one's genetic endowment.

While I basked in the glow of seemingly debunking a particular eugenics argument that I personally found distasteful, one of my astute audience members asked whether the argument I was making could justify discrimination based on one's impoverished upbringing—because they were much more likely to be born in the context of poor maternal nutrition, substandard prenatal care—and these “epigenetic” factors would likely deleteriously affect their physical and mental development. In other words, was I tearing down eugenics and replacing it with “euepigenics” (somebody please come up with a better word to describe this concept or alert me if one already exists—discrimination based on one's epigenome)? My response was that of course, people with ill-intent could interpret some epigenetic research findings as a “rational basis” to discriminate against groups or individuals that have a certain epigenetic profile. However, on the flip side, one could view the relative malleability of the epigenome, in contrast to the genome, as an opportunity to enact policies that could have a dramatic positive impact on one's capabilities. For example, a policy to direct more resources for maternal nutrition and prenatal care could hopefully ensure improved physical and mental development for subsequent children and the benefits would last a lifetime if not several generations.

This brings me back to the debate over the “culture of poverty.” To the questioner mentioned above, I replied that just as with genetics research, we need to be aware of the ethical implications of epigenetic research, and be wary of scientific findings being twisted to rationalize clearly unjust laws and policies (e.g., see Buck v. Bell, http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court=us&vol=274&invol=200 ). To impede scientific inquiry because it might be misinterpreted or misused is not the correct path in my opinion. I think concerns regarding the misuse of epigenetics research--as with genetics research or research on the social aspects of poverty--should be recognized and acknowledged, but that we should not be afraid of otherwise valid academic research even if it has the potential to raise uncomfortable findings. For, therein these findings lies the potential to improve the human condition. Thus, therein these findings lies hope.

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PEBS Neuroethics News Roundup from JHU Guest Blogger

Last Edition's Most Popular Article: How Neuroscience Is Changing the Law, Big Think In The Popular Press: Love and Pain Relief, NY Times Blog Taking Early Retirement May Retire Memory, Too, NY Times Special report: Morality put to the test, New Scientist Gene therapy helps depressed mice, Nature News Film festival: Can monkeys make movies?, New Scientist Robot limbs to plug into the brain with light, New Scientist Can neuroscience help Gap produce a better logo?, New Scientist The science of optical illusions, BBC Old Bees' Memory Fades; Mirrors Recall of Humans and Other Mammals, Science Daily New Mothers Grow Bigger Brains Within Months of Giving Birth: Warmer Feelings Toward Babies Linked to Bigger Mid-Brain, Science Daily La douleur exquise!, Spoonful of medicine From the Academic Literature: Empowering brain science with neuroethics, The Lancet Hypomania Following Bilateral Ventral Capsule Stimulation in a Patient with Refractory Obsessive-Compulsive Disorder, Biological Psychiatry Goal-directed and habitual control in the basal ganglia: implications for Parkinson's disease, Nature Reviews Neuroscience Emotion processing and the amygdala: from a 'low road' to 'many roads' of evaluating biological significance, Nature Reviews Neuroscience Current Steering to Control the Volume of Tissue Activated During Deep Brain Stimulation, Brain Stimulation The neural mechanisms of learning from competitors, NeuroImage Encoding of Motor Skill in the Corticomuscular System of Musicians, Current Biology Temporal patterning of pulses during deep brain stimulation affects central nervous system arousal, Behavioural Brain Research Evidence for Cortical Automaticity in Rule-Based Categorization, Journal of Neuroscience The Architecture of Reward Value Coding in the Human Orbitofrontal Cortex, Journal of Neuroscience STN DBS and Suicide: Is Tangential Evidence, Evidence Enough?, European Neurology Neurophysiological origin of human brain asymmetry for speech and language, PNAS Evidence for a bimodal distribution in human communication, PNAS

Subscribe to our mailing list. The Program in Ethics and Brain Sciences (PEBS) is a collaborative effort of the Johns Hopkins Berman Institute of Bioethics and the  Johns Hopkins Brain Sciences Institute . The goal of PEBS is to ensure that research in brain science proceeds with an informed understanding of ethical issues, and that philosophical and empirical analyses of the advances in brain research proceed with an informed understanding of the science.

Medicating immaturity (L. Syd M Johnson)

Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed behavioral disorder among children. Prescriptions of psychostimulants (such as Ritalin) in children diagnosed with ADHD rose by more than 700 percent between 1991 and 2005. According to a 2006 estimate by the Centers for Disease Control, 4.5 million children under the age of 18 were diagnosed with ADHD; 2.5 million of them regularly use prescription medication to treat ADHD. The dramatic increase in prescription use of stimulants in children is a matter of significant medical and social concern, particularly given the subjective nature of the diagnosis.

Two studies recently published in the Journal of Health Economics reach the same disturbing conclusion: many children are inappropriately disagnosed with ADHD simply because they are immature relative to their classroom peers (Elder doi: 10.1016/j.healeco.2010.06.003 and Evans et al doi:10.1016/j.jheal.eco.2010.07.005). These children are not immature in comparison to their age peers, but in comparison to students  who are, in some cases, a full year older. One of the critically important findings of the studies is that children who turn five before the cutoff date for start of kindergarten (typically September 1 in many US school districts) are significantly more likely to be diagnosed with ADHD than children who miss the cutoff.  The kids who miss the cut off date will be a year older when they start kindergarten, and a year makes a huge difference in level of maturity and behavior in children. Since the actual difference in age between the two groups is only a matter of days or weeks, there should be no difference in the incidence of ADHD diagnosis. But there is.

The Elder study found that ADHD diagnoses among  children born just before their state’s kindergarten eligibility cutoff are more than 60 percent more prevalent than among those born immediately afterward. 10 percent of children born in August are diagnosed with ADHD, compared to 4.5 percent of children born in September. Children born in August are also more than twice as likely to be prescribed stimulants (especially Ritalin), than those born in September. The effect persists throughout the school years. The youngest children in the fifth and eighth grades are twice as likely as their older classmates to regularly use prescribed stimulants to treat ADHD. If these patterns are driven by inappropriate diagnoses, Elder estimates that roughly 20 percent of the 2.5 million children who are treated with stimulants have been misdiagnosed. The driving factor, the author concludes,  appears to be teachers using within-grade comparisons of hyperactivity and inattentiveness, rather than more salient within-age comparisons. As a result, subjectively perceived ADHD “symptoms” in young students “may just reflect emotional or intellectual immaturity among the youngest children in the classroom” (Elder, 642).

These findings are profound and disturbing, and have serious and broad  implications. The financial costs associated with misdiagnosis and treatment are substantial, affecting families, insurance providers, and taxpayers.  Long-term stimulant use may have harmful health effects, including chronically elevated pulse and blood pressure, and attenuated growth in children. No research has been done on the long-term health outcomes of stimulant use in children, and no research (for obvious ethical reasons) has been done on long-term stimulant use in children with no underlying biological or neurological problem. Elder notes, as well, that if younger children are overdiagnosed with ADHD, it is also possible that older children might be underdiagnosed if their behavior is assessed against their younger peers. This could have adverse effects on their academic performance and social adjustment.

It would be interesting to see a socio-economic comparison of children diagnosed with ADHD, because it is likely that socio-economic factors would tend to amplify the problem of age-based misdiagnosis. One of the reasons parents place younger children in school as soon as they are eligible is that keeping them out for an additional year (a practice known as “redshirting” [http://www.nytimes.com/2010/08/22/fashion/22Cultural.html])  imposes substantial economic costs, such as lost work and career years, and daycare expenses. The upshot is that we may be treating a social and economic “disorder” with Ritalin. Greater social support for families of young children, including high quality, subsidized or low-cost daycare, might be a more effective “treatment” than psychostimulants — and with far more salutary side effects — for the diagnosis of immaturity in kindergartners.

Biologically-Active Placebos?

A study reported in the LA Times notes that researchers often fail to disclose the contents of the placebos they use and how these contents may sometimes be relevant to the evaluation of placebo-controlled research.  See here. (Hat tip: May-lee Chai).

PEBS Neuroethics Roundup from JHU Guest Blogger

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Subscribe to our mailing list. The Program in Ethics and Brain Sciences (PEBS) is a collaborative effort of the Johns Hopkins Berman Institute of Bioethics and the  Johns Hopkins Brain Sciences Institute . The goal of PEBS is to ensure that research in brain science proceeds with an informed understanding of ethical issues, and that philosophical and empirical analyses of the advances in brain research proceed with an informed understanding of the science.

Passing the mirror test: reflections on the significance of animal self-awareness (L. Syd M Johnson)

 Anyone who lives with a dog or cat has probably observed that their furry companions ignore mirrors, or if they notice them at all, often behave as if there’s a dangerous interloper on the other side of the looking glass. Dogs and cats fail  the mirror self-recognition (MSR) test, which gauges an animal’s self-awareness by determining whether  it can recognize its own reflection  in a mirror. In the classic version of the test, a small paint mark is placed on an anaesthetized animal’s forehead, and upon awakening, the animal is presented with a mirror. If the animal touches the mark, or otherwise behaviorally  indicates understanding that the mark is on itself, it is concluded that it has passed the test. Cats and dogs are not the only animals to fail the MSR test. So do humans less than 18 months old. Chimpanzees, orangutans, elephants, dolphins, and magpies (PLoS Biol 6(8): e202. doi:10.1371/journal.pbio.0060202)  have passed the MSR test.  Monkeys have not, until recently. Researchers at the University of Wisconsin-Madison, studying how Ritalin affects the prefrontal cortex  in rhesus macaques outfitted with head implants, observed that the monkeys engaged in self-directed behaviors, including extensive examination and touching of the implants as well as examining their own genitals in a mirror. (PLoS ONE 5(9): e12865. doi:10.1371/journal.pone.0012865)

Not everyone is convinced that the rhesus monkeys passed the test, including Gordon Gallup, who devised the mark test in chimpanzees in 1970. But why should we care if animals can pass this test of self-awareness? It is a matter of controversy whether the test really proves what it purports to prove. It is, for one thing, a visual test, so animals that do not rely primarily on their sense of sight are at a disadvantage. Likewise, the test was devised originally in chimpanzees, but other species may, for a variety of reasons, be less sensitive to foreign marks on the forehead. I draw your attention to this sentence from the Wisconsin-Madison paper: “We hypothesize that the head implant, a most salient mark, prompted the monkeys to overcome gaze aversion inhibition or lack of interest in order to look and examine themselves in front of the mirror.” The researchers propose that the rhesus macaques — who have failed the MSR in the past — found the implants in their heads more compelling than a paint mark. The salient ethical feature: these monkeys have large implants protruding from their heads. In the videos accompanying the paper, “The view of the head implant has been blocked for discretion” with a crude black spot. What cannot be obscured is that the monkeys are also housed in tiny steel cages. (http://link.brightcove.com/services/player/bcpid90402333001?bclid=90190339001&bctid=620981260001) Ought we be concerned that self-aware monkeys are kept in small cages with surgical implants protruding from their skulls?

Primates, such as rhesus macaques and chimpanzees, are used extensively in research. The Great Ape Protection Act is currently working its way through the US Congress — the act would prohibit the use of great apes in “invasive research.” In 2000, the US Congress passed the Chimpanzee Health Improvement Maintenance and Protection Act (CHIMP Act), to create a system of sanctuaries for housing surplus chimpanzees that have been “retired” from research. It was deemed inappropriate to euthanize chimps, our closest genetic cousins, once they’ve outlived their usefulness, but not inappropriate to use them in the first place. No comparable restrictions on research, or retirement homes, have been proposed for other research animals, including those self-aware rhesus monkeys. (According to the Humane Society of the US, there are approximately 112,000 rhesus monkeys currently being used for research or breeding in the US.)

What’s the moral significance of self-awareness in animals? There is at least one line of argument to the effect that moral status in animals is contingent on having interests, and having interests is contingent on having mental states, which is contingent on being sentient. (See e.g. David Degrazia’s Taking Animals Seriously). But the MSR test is not a test of sentience, per se. Gallup explains the significance of  self-awareness thusly: “self-awareness is defined as the ability to become the object of your own attention, consciousness as being aware of your own existence, and mind as the capacity to be aware of your own mental states…” (Gallup G “Do minds exist in species other than our own?” Neuroscience & Behavioral Reviews 9(1985):631-41).  Gallup goes on to claim that “either you are aware of being aware or you are unaware of being aware, and the latter is tantamount to being unconscious.” And there’s the rub: animals that are not self-aware are not conscious, or so the story goes. Surely we cannot harm unconscious animals, and surely we do not owe them anything (such as humane treatment). If the presence of self-awareness is our sole criterion for moral consideration, then any animal who fails the MSR test just doesn’t warrant it. But it is quite extraordinary to suggest that a mouse, or your cat — or that mouse trying to escape your cat — is not conscious, based on an inability to convincingly indicate that it can recognize itself in a mirror. Indeed,  it strikes me as implausible to even say that they lack self-awareness. Certainly the cat and mouse must possess other-awareness, hence the cat chases the mouse, and the mouse runs from the cat, but not from other mice. But Gallup argues that “awareness presupposes self-awareness,” which is to say that the mouse, or the cat,  is not aware at all. That also means, if we take the MSR to be universal and definitive, that the year old human infant, or the blind person, or the prosopagnosiac is also not self-aware, and  is not conscious. And that is absurd.

One way to avoid this absurdity is to abandon the MSR test as a valid, universal test of self-awareness. A blind person, or a prosopagnosiac surely has other ways of proving that she is self-aware and conscious. An ordinary human infant, one who learns and responds and interacts with the world, may (arguably) not be self-aware, but  is surely conscious, and so is the cat. The MSR is not sensitive to the natural behaviors and inclinations of a species, or to the developmental stage, environment, and learning of an animal — hence, for example, the controversial and inconsistent findings on gorillas, who have learned to communicate with human sign language, but repeatedly fail the MSR test. More fundamentally, we can avoid absurdity — and moral dissonance (and the need to discretely hide ugly head implants) — by abandoning the notion that certain types of cognition, or cognitive abilities, or behaviors, are indicators of moral status that allow us to create a moral hierarchy, with humans at the top, and chimpanzees, dolphins, and other creatures in the exclusive MSR club somewhere below us, worthy of some limited degree of concern and care, and the rest of the animal kingdom even  lower, there to be used as we see fit. But even if we accept that there’s a justifiable moral hierarchy, and a corresponding hierarchy of moral concern and moral obligation, we still need to justify keeping an intelligent, self-aware animal in a tiny steel cage, surgically implanting a box in its skull, and feeding it Ritalin.

PEBS Neuroethics Roundup from JHU Guest Blogger

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Subscribe to our mailing list. The Program in Ethics and Brain Sciences (PEBS) is a collaborative effort of the Johns Hopkins Berman Institute of Bioethics and the  Johns Hopkins Brain Sciences Institute . The goal of PEBS is to ensure that research in brain science proceeds with an informed understanding of ethical issues, and that philosophical and empirical analyses of the advances in brain research proceed with an informed understanding of the science.

Kids, concussion and ConTACT: the shortcomings of return to play guidelines (L. Syd M Johnson)

Last week, the US House of Representatives passed HR 1347, the Concussion Treatment and Care Tools Act of 2009 (aka ConTACT — gotta love those creative acronyms), a bill mandating the establishment of federal guidelines for managing concussions in student athletes. The bill requires the Secretary of Health and Human Services to convene a conference of medical, athletic and education experts to set guidelines for the prevention, identification, treatment and management of concussion in school-aged children, including return to play standards for student athletes who sustain concussions.

Concussion management has been understudied in the pediatric population, and there currently exist no evidence-based return to play guidelines for sport-related concussion in children, but the Zurich Consensus Statement (http://bjsm.bmj.com/content/43/Suppl_1/i76.full) proposes that children never return to play on the same day of injury, and return to practice and play only when clinically symptom free. An extended period of cognitive rest is also recommended. There is considerable neuroscientific and neuropsychological evidence, however, that concussion results in long lasting impairments of attention, concentration, processing speed and mental flexibility in children, which can have a dramatic effect on a young person’s ability to cope with basic educational tasks for a year or more. These negative cognitive effects of concussive injury on scholastic performance and behaviour may persist long after the clinical symptoms and measurable neuropsychological impairment have resolved. Moreover, these subtle effects appear to be cumulative and potentially permanent, possibly due to the impairment of critical brain plasticity, putting athletes at particular risk, since they are most likely to suffer repeated concussions.

In light of increasing concern about the impact of concussion on student athletes, laws like ConTACT have been adopted by the states, the first and most notable being Washington State’s Lystedt Law (2009). The Lystedt Law was named after Zackery Lystedt, a 13 year old football player who sustained a concussion in a junior high football game. After returning to play in the same game, he suffered a second, devastating brain injury that has left him permanently disabled. The Lystedt Law aims to prevent secondary injuries that result from Second Impact Syndrome, a rare, often fatal cascade of irreversible neuro-metabolic events that results in catastrophic brain swelling leading to death or severe disability. Children are especially vulnerable to Second Impact Syndrome. The Lystedt law mandates the removal from play of children who are suspected of sustaining a concussion, and requires written medical clearance from a licensed healthcare provider before return to play. The National Football League, itself under fire for its policies regarding brain injured athletes, has urged all states to adopt similar legislation.

The Lystedt Law, and similar guidelines, are an important starting point in addressing the problem of sport-related concussion in children. However, these guidelines do not go far enough. Because return to play guidelines are only designed to prevent secondary injuries, they do nothing to address the core problem of sport-related concussion, and numerous confounding factors make the guidelines ineffective. (see http://www.nytimes.com/2010/09/23/sports/23concussion.html?scp=1&sq=concussion%20lystedt&st=cse for a good discussion of one town’s experience with the Lystedt requirements.) One problem is that most junior level sports teams lack personnel adequately trained in concussion detection and treatment. Because concussion management is poorly understood in the pediatric population, few healthcare providers possess the specialized training needed to assess concussion in children. Moreover, accurate assessment of concussion recovery requires baseline neuropsychological testing of athletes, which is not required by the Lystedt Law. The protective impact, therefore, of simply requiring medical evaluation and clearance following concussion is minimal, and likely to do as much harm as good, since it can create the illusion of safety. Finally, return to play guidelines may be financially onerous for teams and athletes who lack the resources to obtain baseline testing and post-concussive medical evaluation of student athletes. If economically disadvantaged teams are prohibited from playing, it removes opportunities for young athletes to take advantage of the benefits of athletic activity. If economically disadvantaged athletes are allowed to play under less safe conditions than their opponents — teams that have the resources to protect their athletes better — they face the risk of long term disability and impairment that may further exacerbate existing disadvantages.

ConTACT, in addition to mandating the development of federal return to play guidelines, authorizes HHS to make grants to states to fund “implementation by schools of computerized preseason baseline and post-injury neuropsychological testing for student athletes.” This is a critically needed adjunct to return to play guidelines, and one that can help address the shortcomings of previous return to play mandates, and help level the playing field for all student athletes. The more challenging problem is to find ways to make sports participation safer for young athletes — to prevent concussions, and not just secondary brain injuries. To do that may require radically rethinking and reimagining sports for children. Whether or not the social and political will to do so exists remains to be seen.

The new DSM: a challenge for neuroscience in court (Andrea Lavazza and Mario De Caro)

The forthcoming new edition of the Diagnostic and Statistical Manual of Mental Disorders – the main reference work for the classification of mental disorders, whose fifth edition is due for publication in May 2013 – is already generating extensive debate. A sign of the fast-growing influence of DSM at a social level is offered by the concern, if not the panic, of some culturally and politically conservative groups. Few days ago, for example, several Italian MPs (belonging to the country’s biggest party) issued an interrogation to the Ministry of Health: they asked him to do everything he could in order to prevent the DSM V from including “preposterous” or “nonsensical” disorders, such as premenstrual syndrome, which in the MPs’ opinion, is “a physiological condition experienced by all women”.

These exaggerated fears are a sign of how influential the DSM is. Nowadays it is used worldwide by clinicians, national health agencies, private companies and policy makers. But with the increasingly important role played by scientific evidence in court, it is going to become a relevant reference in jurisprudence as well. One of the reasons why professionals in the legal field should pay attention to the new DSM has been made clear by Leonardo Tondo, a psychiatrist who was asked to write a couple of DSM’s entries. In Tondo’s opinion, the identification of new psychiatric disorder depends, at least in part, on the desire to help potential patients to get refunded for their psychiatric care expenses and to prevent people affected by mental disorders from being held legally responsible for the damages caused by their behaviour. This legally “exempting” aspect of the new formulation of disorders set out in the new edition of the DSM is strengthened by several attempts at individuating causal links between mental disorder and clearly identifiable cerebral lesions or dysfunctions – even if, of course, we are still very far away from precisely identify those causal links in the most relevant cases (think of schizophrenia, for example).

Many psychiatrists and philosophers feel nowadays that behaviours that violate the law and are included in the DSM-5 should not be considered of a criminal sort, since they are the products of neural disorders over which individuals have little or no control.  In a society that increasingly, sometimes uncritically, accepts the idea that “one is one’s brain” (while one is seen as unable to control what happens in one’s brain), it could be argued that the broader the DSM, the narrower the penal code. For example, if compulsive hoarding disorder makes it into the DSM-5, will it be possible to convict a person whose heavy heaps of stuff cause the floor to collapse on the heads of his downstairs neighbours? Undeniably, therefore, the influence of the DSM on the application of the law is going to greatly increase in the next years. Still, the law is very much behind in matching itself with our knowledge of mental diseases (for example, the judicial systems seem to neglect the fact that the number of disorders included in the DSM has remarkably increased since its first edition in 1952). Much work has to be done in this respect.

According to many, a more humane jurisdiction could derive from a careful application of the DSM in our courts. It may be so. In this light, however, the research programs that aim at reducing mental diseases to neurological lesions or dysfunctions should be developed carefully and without strained ideological interpretations.

PEBS Neuroethics Roundup from JHU Guest Blogger

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