In this episode, Senior Academic Specialist Libby Bogdan-Lovis is joined by Dr. Sarah Pletcher, Vice President and Executive Medical Director of Virtual Care at Houston Methodist. Dr. Pletcher shares her telehealth expertise in a conversation that explores the benefits of telehealth for patients and providers, the influence of the COVID-19 pandemic on telehealth adoption, reimbursement models, the future of telehealth, and more.
This episode was produced and edited by Liz McDaniel in the Center for Bioethics and Social Justice. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.
About: No Easy Answers in Bioethics is a podcast series from the Center for Bioethics and Social Justice in the Michigan State University College of Human Medicine. Center faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.
The search for a brain device capable of capturing recordings from thousands of neurons has been a primary goal of the government-sponsored BRAIN initiative. To succeed would require developing flexible materials for the electrodes, miniaturization of the electronics and fully wireless interaction. Yet this past summer, it was corporately funded Facebook and Elon Musk’s Neuralink that stepped forward with announcements regarding their respective technological investment to access and read our human brains.
Elon Musk, the eccentric technology entrepreneur and CEO of Tesla and Space X, made a big announcement while at the California Academy of Sciences. This time it was not about commercial space travel or plans to revolutionize city driving. Instead Musk presented advances on a product under development at his company Neuralink. The product features a sophisticated neural implant which aims to record the activities of thousands of neurons in the brain, and write signals back into the brain to provide sensory feedback. Musk mentioned that this technology would be available to humans as early as next year.
Mark Zuckerberg’s Facebook is also funding brain research to develop a non-invasive wearable device that would allow people to type by simply imagining that they are talking. The company plans to demonstrate a prototype system by the end of the year.
These two corporate announcements raise important questions. Should we be concerned about the introduction of brain devices that have the capacity to read thousands of neurons and then send signals to our brains? The initial goal for both products is medical, to help paralyzed individuals use their thoughts to control a computer or smartphone, or in the case of Facebook to help those with disabling speech impairments. However, these products also are considered to be of interest to healthy individuals who might wish to “interact with today’s VR systems and tomorrow’s AR glasses.” Musk shared his vision to enable humans to “merge” with Artificial Intelligence (AI), enhancing them to reach superhuman intelligence levels.
Time will tell whether or not these grand visions, that currently veer into science fiction, will be matched by scientific progress. However, if they ultimately deliver on their promise, the products could change the lives of those affected by paralysis and other physical disabilities. Yet, if embraced by healthy individuals such technologies could radically transform what it means to be human. There are of course sound reasons to remain skeptical that they will be used. First off there are safety issues to be considered when implanting electrodes in the brain, including damage to the vasculature surrounding the implant as well as tissue response surrounding the device. And that is what is currently known about inserting brain-computer interfaces with only a couple of electrode channels. Consider what might happen with thousands of electrodes. There remain simply too many unknowns to endorse this intervention for human use in the next year or so. There also are salient issues regarding brain data collection, storage, and use, including concerns connected to privacy and ownership.
Beyond these concerns, we have to think about what happens when such developments are spearheaded by private companies. Privately funded development is at odds with the slow, careful approach to innovation that most medical developments rely upon, where human research subject regulations and safety measures are clear. It is the “move fast and break things” pace that energizes start-up companies and Silicon Valley entrepreneurs. The big swings at the heart of these entrepreneurial tech companies also bring considerable risks. When addressing sophisticated brain interfaces, the stakes are quite high. These products bring to mind scenarios from Black Mirror, a program that prompts a host of modern anxieties about technology. On one hand, the possibility of having a brain implant that allows hands-free device interaction seems exciting, but consider the level of information we then would be giving to these companies. It is one thing to track how individuals react to a social media post by clicking whether they “like” it or not, or by how many times it has been shared. It is another thing altogether to capture which parts of the brain are being activated without us having clicked anything. Can those companies be trusted with a direct window to our thoughts, especially when they have a questionable track record when it comes to transparency and accountability? Consider how long it took for Facebook to start addressing the use of customer’s personal information. It remains unclear just how much financial support Facebook is providing to its academic partners, or whether or not volunteers are aware of Facebook’s involvement in the funding-related research.
The U.S. Food and Drug Administration as well as academic partners to these enterprises may act as a moderating force on the tech industry, yet recent examples suggest that those kinds of checks and balances oftentimes fail. Thus, when we hear about developments by companies such as Facebook and Neuralink trying to access the thoughts in our brains, we need to hold on to a healthy skepticism and continue to pose important challenging questions.
Laura Cabrera, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Neuroscience 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, September 26, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.
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I love puzzle rooms and detective novels. When medicine looks like a puzzle room, I become fascinated as a non-MD aspiring detective. When that medical mystery reveals an ethical problem, I really get in gear, as a clinical (neuro) ethicist.
Reading about the “Mystery of sonic weapon attacks at US embassy in Cuba” made me consider how physicians engage in a puzzle, and how piecing the story together leads to a hypothesis, as if in a puzzle room. Patients with strange and mysterious medical symptoms, suspicious circumstances, and the culprit? Uncertain – inexplicable narratives, patterns, and complaints that do not head in a clear prognostic direction. A story that continues to unravel. Doctors are detectives, and medicine can be a journey through a puzzle room to discover clues about the cause of ailments. Within the story, technology is the enemy but perhaps also a friend; providers embrace technology as it seems to promise a definitive answer.
The ethical problem: We do not make patients privy to the fact that medicine is something of a puzzle room, and that medicine’s technological tools carry substantial uncertainty. Instead, medical technology is presented as offering the path to a concrete solution. Uncertainty is rarely addressed by providers, or presented to patients who pay for expensive technologies, and equally who might suffer under their use. The medical world operates in a political and cultural system, which affects how providers want to see symptoms and technology. Patients get carried along with the tide. The embassy story made me think about the role of a clinical ethicist. Who challenges the patient, who challenges the doctor, who challenges the technology? Should clinical ethicists be detectives too?
What is/was going on in the Cuba case? Early news storiesreported that a sonic weapon might have harmed American diplomats. Diplomats claimed hearing loss, speech problems, vision issues and nausea after perceiving high-pitched noises and thumps. Canadian diplomats (and their children!) might have been harmed too. Reports indicated uncertainty about the culprit: “None of this has a reasonable explanation.” Experts submitted that no detrimental sonic weapon with this power had yet been developed. However, plagued by symptoms, diplomats were called back for safety reasons; reasonably, they were not expected to endure permanent threats to their health, lives and livelihood.
Since the diplomats had not experienced blunt trauma, their condition was baffling. Research, as JAMA published, suggested that many of the 21 study participants showed various “objective” signs that could indicate neurologic injury, i.e., symptoms often found in individuals post-concussion. About the culprit, the authors stated: “The unique circumstances of these patients and the consistency of the clinical manifestations raised concern for a novel mechanism of a possible acquired brain injury from a directional exposure of undetermined etiology.” Per the study, MRI findings indicated a shift change in white matter, possibly suggesting a neurological foundation to the problem.
Critics of the study were less sure (see references 3, 5, 6, and 8 below). They questioned the MRI tool and laid out different approaches to the puzzle, in full public view. Critical analysists, including a Cuban author, labeled the symptoms as potentially psychosomatic, the result of a conversion disorder. Suggesting a mass-psychogenic illness, the authors submitted that the hype around Cuba generated a “bias,” creating anxiety and hypersensitivity. They contested the finding’s objectivity as based on self-report or subjective interpretations of the researchers. Hence objective conclusions were elusive. Critics offered that: “Medical diagnosis at any given time depends to some extent on the current state of scientific knowledge, historical and cultural context, and the framework through which a disease is conceptualized.” However, this context was explicitly ignored by another expert who favored a physical approach. In a Neurology Today article by Dan Hurley, Dr. Terry Fife stated: “Just because an MRI is normal doesn’t mean everything else is normal. Many conditions in the past that we thought were subjective turned out to be quite real.”
Intrigue around the sonic attacks made me consider how mechanistic conclusions are rarely called into question. In this case, the critical perspective came from fellow physicians, which is reassuring; the system does not often question mechanistic truths. I wonder what mechanisms exist in the real life clinic? I hear about cases in which the most powerful physician might reference MRI results, and oppose the withdrawal of life support. Contrary to the whole team of other providers, who describe the clinical picture as awful and exacerbating the patient’s suffering, as well the family, who indicate that the patient would not want continued life support, the physician objects to withdrawal, stating that the MRI tool does not confirm the clinical picture; this physician wishes to continue full steam ahead. Without questioning his tool (i.e., the MRI), or the technological questions of his colleagues, the patient is unreasonably made to suffer.
Tools to facilitate any type of “certainty,” like MRIs, are popular reference points used to instill trust in our patients and our families. Just as the detective’s magnifying glass stands for scrutiny and expertise, the stethoscope stands for the physician’s trustworthiness. In foggy medical settings, heart monitors and MRI machines are powerful symbols to generate certainty and clarity. The health care setting presents them as supersonic tools. In cases where the results are questioned, the setting proposes that the patient must be “wrong” and not the technology. As illustrated in the Cuban diplomats’ case, the alternative explanation for their symptoms goes straight to mass psychogenic illness. Instead of having a somatic origin, because we could not view something, the symptoms must be caused by a mental state.
What is the role of a clinical ethicist within this culture? The story made me consider how much we need to walk into the medical puzzle room. Especially where medical tools are obstacles because of their presumed “definitive” clarity. Where physicians ignore questionable methodologies, should ethicists then be the detective? Pull out their magnifying glass, and use their tools of critical questions? Who should ask what is real and what is not? Whose role is it to challenge the patient, the doctor, the technology?
Marleen Eijkholt, JD, PhD,is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology in the Michigan State University College of Human Medicine. Dr. Eijkholt is also a Clinical Ethics Consultant at Spectrum Health System.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 31, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.
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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.
In recent years, several research groups have been able to infer the contents of subjects’ thoughts from fMRI scans. E-commerce sites are tracking customers’ purchases and making ever better predictions about what people will buy. What are the prospects for such technology to be widely used? Are there fundamental technical limitations?
We may readily imagine dystopian scenarios for such technology, where privacy as we have known it is no longer meaningful, and the powerful monitor the thoughts of everyone else. We may also imagine that therapists could better communicate with autistic or troubled people, or to detect incipient mental illness.
Join us for Dr. Reimer’s lecture on Wednesday, November 29, 2017 from noon till 1 pm in person or online.
Mark Reimers, PhD, is anAssociate Professor in the Neuroscience Program in the College of Natural Science at Michigan State University. Dr. Reimers’ research focuses on analyzing and interpreting the very large data sets now being generated in neuroscience, especially from the high-throughput technologies developed by the BRAIN initiative. He obtained his MSc in scientific computing, and his PhD in probability theory from the University of British Columbia in Canada. He has worked at Memorial University in Canada, the Karolinska Institute in Stockholm, at several start-up companies in Toronto and in Boston, at the National Institutes of Health in Maryland, the Virginia Institute for Psychiatric and Behavioral Genetics in Richmond, and since January 2015 in the Neuroscience Program at Michigan State University.
In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.