Dr. Robyn Bluhm, Associate Professor in the Department of Philosophy and Lyman Briggs College, and Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Neuroscience, are co-authors of an article in the Spring 2020 issue of IJFAB: International Journal of Feminist Approaches to Bioethics.
Their article, “Deep Brain Stimulation and Relational Agency: Negotiating Relationships,” appears in a special section on feminist neurotechnologies. From the article’s introduction:
In this commentary, we consider three aspects of [Timothy] Brown’s discussion of DBS and relational agency: (1) the importance of thinking critically about what it means to have a relationship with a DBS device; (2) how the development of “closed loop” implants might change the kinds of relationships that are possible; and (3) the need to consider how an individual’s relationship with their device is shaped by their relationship with others in their lives. We see ourselves as building on, or offering suggestions for further developing, Brown’s important paper.
Drs. Bluhm and Cabrera are co-investigators on the project “Is the Treatment Perceived to be Worse than the Disease?: Ethical Concerns and Attitudes towards Psychiatric Electroceutical Interventions,” funded by the NIH BRAIN Initiative. Deep brain stimulation (DBS) is one of four types of psychiatric electroceutical interventions (PEIs) included in the scope of the project.
The full text is available online via University of Toronto Press (MSU Library or other institutional access may be required to view this article).
Center for Ethics Assistant Professor Dr. Laura Cabrera and Associate Professor Dr. Karen Kelly-Blake, along with Dr. Christos Sidiropoulos of the Department of Neurology & Ophthalmology, are co-authors of a new article in Brain Sciences. Their article “Perspectives on Deep Brain Stimulation and Its Earlier Use for Parkinson’s Disease: A Qualitative Study of US Patients” appears in a special issue on “Brain Stimulation and Parkinson’s Disease.”
Background: Deep brain stimulation (DBS) is being used earlier than was previously the case in the disease progression in people with Parkinson’s disease (PD). To explore preferences about the timing of DBS, we asked PD patients with DBS whether they would have preferred the implantation procedure to have occurred earlier after diagnosis. Methods: Twenty Michigan-based patients were interviewed about both their experiences with DBS as well as their attitudes regarding the possible earlier use of DBS. We used a structured interview, with both closed and open-ended questions. Interviews were transcribed verbatim and analyzed using a mixed-methods approach. Results: We found that the majority of our participants (72%) had high overall satisfaction with DBS in addressing motor symptoms (mean of 7.5/10) and quality of life (mean of 8.25/10). Participants were mixed about whether they would have undergone DBS earlier than they did, with five participants being unsure and the remaining nearly equally divided between yes and no. Conclusion: Patient attitudes on the early use of DBS were mixed. Our results suggest that while patients were grateful for improvements experienced with DBS, they would not necessarily have endorsed its implementation earlier in their disease progression. Larger studies are needed to further examine our findings.
An article by Center Assistant Professor Dr. Laura Cabrera has been published in the November 2019 issue of Bioethics. The article, “A human rights approach to low data reporting in clinical trials of psychiatric deep brain stimulation,” advocates for “the importance of reporting clinical trial data of invasive procedures in highly vulnerable populations, such as psychiatric DBS trials.”
Abstract: The reporting of clinical trial data is necessary not only for doctors to determine treatment efficacy, but also to explore new questions without unnecessarily repeating trials, and to protect patients and the public from dangers when data are withheld. This issue is particularly salient in those trials involving invasive neurosurgical interventions, such as deep brain stimulation (DBS), for ‘treatment refractory’ psychiatric disorders. Using the federal database ClinicalTrials.gov, it was discovered that out of the completed or unknown‐status trials related to psychiatric DBS up to November 2018, only two had submitted results to ClinicalTrials.gov. These results suggest that, despite federal requirements to report clinical trial data, reporting on psychiatric DBS trials is problematically minimal. It is argued that a human rights approach to this problem establishes a legal and ethical foundation for the need to report clinical trial results in this area.
The full text is available online via Wiley Online Library (MSU Library or other institutional access may be required to view this article).
Center Assistant Professor Dr. Laura Cabrera is co-author of an article in the August 2019 issue of World Neurosurgery. In “Perspectives on the Earlier Use of Deep Brain Stimulation for Parkinson Disease from a Qualitative Study of U.S. Clinicians,” authors Dr. Cabrera, Dr. Harini Sarva (Weill Cornell Medical College), and Dr. Christos Sidiropoulos (Michigan State University Department of Neurology & Ophthalmology) share the results of Michigan-based clinician interviews about the use of deep brain stimulation (DBS) therapy in people with Parkinson’s disease. They conclude that there is a wide variation in clinicians’ parameters for when they suggest DBS as a treatment option for their patients.
The full text is available online via Science Direct (MSU Library or other institutional access may be required to view this article).
Center Assistant Professor Dr. Laura Cabrera and co-authors Dr. Robyn Bluhm and Rachel McKenzie have a new article available online in Neuroethics, “What we (Should) Talk about when we Talk about Deep Brain Stimulation and Personal Identity.” The article resulted from the team’s Science and Society at State funded project on “Psychiatric Interventions: Values and Public Attitudes.”
Abstract: A number of reports have suggested that patients who undergo deep brain stimulation (DBS) may experience changes to their personality or sense of self. These reports have attracted great philosophical interest. This paper surveys the philosophical literature on personal identity and DBS and draws on an emerging empirical literature on the experiences of patients who have undergone this therapy to argue that the existing philosophical discussion of DBS and personal identity frames the problem too narrowly. Much of the discussion by neuroethicists centers on the nature of the threat posed by DBS, asking whether it is best understood as a threat to personal identity, autonomy, agency, or authenticity, or as putting patients at risk of self-estrangement. Our aim in this paper is to use the empirical literature on patients’ experiences post-DBS to open up a broader range of questions – both philosophical and practical, and to suggest that attention to these questions will help to provide better support to patients, both before and after treatment.
The full text is available online via Springer Link (MSU Library or other institutional access may be required to view this article).
“Interpreting Patients’ Beliefs About Deep Brain Stimulation for Treatment-Resistant Depression: The Need for Caution and for Context” is an open peer commentary available in the latest AJOB Neuroscience issue. Michigan State University co-authors Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine, and Dr. Robyn Bluhm, Associate Professor in the Department of Philosophy and Lyman Briggs College, are currently working on an NIH BRAIN Initiative funded project on a related topic.
Dr. Cabrera and Dr. Bluhm focus on two points raised by the Lawrence et al. paper. First, they discussed a couple methodological decisions made by the authors which may have had an important influence on the results presented in the article. The second point relates to the work of Dr. Cabrera and Dr. Bluhm, examining differences in the bioethics literature’s discussion of deep brain stimulation and public comments on newspaper and magazine studies covering the intervention; this part of the open peer commentary shows how their findings can help to deepen the analysis by Lawrence et al.
The full text is available online via Taylor & Francis Online (MSU Library or other institutional access may be required to view this article).
Continue reading below for a list of recent journal articles from Center faculty, including online first publications. MSU Library or other institutional access may be required to view these articles.
Recently assigned an issue
Stahl D. Patient reflections on the disenchantment of techno-medicine. Theoretical Medicine and Bioethics. December 2018;39(6):499-513. Available online November 1, 2018. View full text via Springer Link.
Cabrera LY, Bittlinger M, Lou H, Müller S, Illes J. Reader comments to media reports on psychiatric neurosurgery: past history casts shadows on the future. Acta Neurochirurgica. December 2018;160(12):2501-2507. Available online October 24, 2018. View full text via Springer Link.
Fleck LM. Healthcare Priority-Setting: Chat-Ting Is Not Enough; Comment on “Swiss-CHAT: Citizens Discuss Priorities for Swiss Health Insurance Coverage”. International Journal of Health Policy and Management. October 2018;7(10):961-963. Available online July 28, 2018. View full text via IJHPM.
Zhuang J, Bresnahan M, Zhu Y, Yan X, Bogdan-Lovis E, Goldbort J, Haider S. The impact of coworker support and stigma on breastfeeding after returning to work. Journal of Applied Communication Research. 2018;46(4):491-508. Available online July 19, 2018. View full text via Taylor & Francis Online.
Cabrera LY, Brandt M, McKenzie R, Bluhm R. Comparison of philosophical concerns between professionals and the public regarding two psychiatric treatments. AJOB Empirical Bioethics. Available online November 6, 2018. View full text via Taylor & Francis Online.
Bluhm R, Cabrera LY. It’s Not Just Counting that Counts: a Reply to Gilbert, Viaña, and Ineichen. Neuroethics. Available online October 27, 2018. View full text via Springer Link.
De Vries RG, Ryan KA, Gordon L, Krenz CD, Tomlinson T, Jewell S, Kim SYH. Biobanks and the Moral Concerns of Donors: A Democratic Deliberation. Qualitative Health Research. Available online August 10, 2018. View full text via SAGE Journals.
Cabrera LY, Goudreau J, Sidiropoulos C. Critical appraisal of the recent US FDA approval for earlier DBS intervention. Neurology. 2018. Available online June 13, 2018. View full text via Neurology.
Zhuang J, Bresnahan MJ, Yan X, Zhu Y, Goldbort J, Bogdan-Lovis E. Keep Doing the Good Work: Impact of Coworker and Community Support on Continuation of Breastfeeding. Health Communication. Available online May 17, 2018. View full text via Taylor & Francis Online.
Should we be worried about the use of direct brain stimulation to improve memory? Well, it depends. If we think of people with treatment refractory memory conditions, or those situations where drugs are not helping the patient, such an approach might seem like the next sensible step. There is reason, however, to remain skeptical that this strategy should be used to improve the memories of people who function within a normal memory spectrum.
The quest to improve memory is hardly new. Throughout time people have engaged in ways to improve their memories, such as eating particular foods, employing mnemonic strategies, or taking certain drugs, but the quest does not end there. A recent New York Times article discussed findings from a direct brain stimulation study (Ezzyat et al., 2018) on the possibility of using brain stimulation to rescue functional networks and improve memory. In that study, 25 patients undergoing intracranial monitoring as part of clinical treatment for drug-resistant epilepsy were additionally recruited with the aim of assessing temporal cortex electrical stimulation on memory-related function.
The prospect of using brain stimulation to improve memory, initially introduced in the 1950s (Bickford et al., 1958) re-emerged in 2008 when a study using hypothalamic continuous deep brain stimulation (aka open-loop DBS) to treat a patient with morbid obesity revealed an increased recollection capacity in that same patient (Hamani et al., 2008). Subsequent studies have attempted to prove that direct brain stimulation is useful for memory improvement. However, the data on open-loop deep brain stimulation currently remains inconclusive.
The approach by Ezzyat and colleagues, wherein neural activity is monitored and decoded during a memory task, suggests an improvement over open-loop approaches. In this treatment modality stimulation is delivered in response to specific neural activity, detecting those times when the brain is unlikely to encode successfully and rescuing network activity to potentially improve overall performance.
In that study stimulation was triggered to respond exclusively to those patterns of neural activity associated with poor encoding, effectively rescuing episodes of poor memory and showing a 15% improvement in subsequent recall. Indeed, those results might sound promising, but this type of memory intervention raises a number of ethical issues.
In a very direct fashion memory is related to the core of who we are. It allows us to build an interpretation of ourselves and our environments, and in so doing gives us orientation in time as well as in our moral life. As surrealist Luis Bunuel put it, “Life without memory is no life at all … Our memory is our coherence, our reason, our feeling, even our action. Without it, we are nothing …” Equally, memory plays a crucial role in cognition, learning, and performance, and as such it is not a surprise that many people feel particularly drawn to memory improvement strategies. Yet there are salient, concerning issues when directly meddling with the human brain, including those risks associated with deep electrode insertion such as infection, hemorrhage, seizure and hardware complications. One might reasonably question whether a 15% memory improvement is worth such high stakes risks?
Another concern is the potential for undesirable – but as yet undetermined – side effects. Those uncertainties are why it seems unlikely that such an approach will be used in healthy individuals or for mild memory dysfunction cases. Still and yet, closed-loop deep brain stimulation has alternative utility. It can be used to improve understanding about the specific brain target most centrally related to certain memory functions, and then use that information to employ less invasive interventions, such as transcranial magnetic stimulation (TMS).
The sorts of studies engaged by Ezzyat’s team and others overlook the fact that memories are not just physically located within the cranial cavity. We have external technologies such as photographs, videos, and agendas to help us remember, and so one might reasonably ask if we really need invasive brain implants to achieve the same ends? The brain’s plasticity is equally overlooked, erroneously assuming that the same brain targets will bring equivalent outcomes for healthy individuals as well as for those with memory impairments. Moreover, the identified interventions improve memory encoding, but do not help with the many errors to which memory is perplexingly prone, such as misattribution, suggestibility, and bias. For healthy individuals, addressing those common memory errors could potentially be more helpful than improving encoding with brain stimulation.
In addition, certain types of memory enhancement could bring new perspectives on one’s life, and even affect the ability to understand the past and imagine the future. In fact if we truly were to remember everything we encounter in our lives we might well be overburdened with memories, unable to focus on current experiences and afflicted by persistent memories of those things that we deem unimportant.
Open-loop neural implants already bring a different configuration of human agency and moral responsibility. Closed-loop implants with their ability to both stimulate and continuously monitor neural patterns bring further issues for consideration, such as neurosecurity (e.g. brain hacking) and mental privacy. Improved connectivity of this type of implant further enables the potential for malicious interference by criminals. Concerns about mental privacy figure prominently in other neurotechnologies, which, similar to brain implants, have the ability to access neural data correlated with intentions, thoughts, and behaviors. This enhanced proximity encroaches on the core of who we are as individuals, providing access to mental life that in the past was accessible only to oneself.
Finally, the media hype in itself is problematic. The New York Times’ article mentioned that the 15% improvement observed in the Ezzayt study was a noticeable memory boost. This sort of inflated media coverage does a disservice to the good intentions and professional rigor of scientists and engineers, and misleads the reader to be either overly-optimistic or overly-worried about the reported developments.
With these many considerations in mind, it is clear that direct brain stimulation will replace neither pharmaceuticals nor less invasive memory improvement options anytime soon. Those who crave memory improvement through memory intervention technologies might best be mindful of the aforementioned ethical and social considerations.
Laura Cabrera, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine at Michigan State University.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 10, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.
You must provide your name and email address to leave a comment. Your email address will not be made public.
Center Assistant Professor Dr. Laura Cabrera recently returned from Germany, where she presented research at the Herrenhausen Conference held in Hanover. The conference, “Lost in the Maze? Navigating Evidence and Ethics in Translational Neuroscience,” focused on major scientific and ethical challenges of novel neurological interventions and how they can be overcome.
Dr. Cabrera was one of the young researchers selected to present her research on “Responsible Translation of Contemporary Neuroscientific Advances: A Critical Appraisal of the Recent U.S. FDA Approval for Earlier DBS Intervention in Parkinson Disease” as a flash talk and a poster.
Episode 5 of No Easy Answers in Bioethics is now available! This episode features guests Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine, Dr. Robyn Bluhm, Associate Professor in the Philosophy Department and Lyman Briggs College, and undergraduate research assistant Rachel McKenzie. Together at Michigan State University they have collaborated on research regarding psychiatric interventions, including pharmacological interventions as well as neurosurgery, like deep brain stimulation. In this episode they share some highlights from their internally-funded Science and Society at State project, which focused on the public perceptions of such psychiatric interventions.
This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full transcript available.
About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.