Today the measurable health burden of neurological and mental health disorders matches or even surpasses any other cluster of health conditions. At the same time, the clinical applications of recent advances in neuroscience are hardly straightforward. In Pragmatic Neuroethics, Eric Racine argues that the emerging field of neuroethics offers a way to integrate such specialties as neurology, psychiatry, and neurosurgery with the humanities and social sciences, neuroscience research, and related healthcare professions, with the goal of tackling key ethical challenges and improving patient care. Racine provides a survey of the often diverging perspectives within neuroethics, offers a theoretical framework supported by empirical data, and discusses the neuroethical implications of such issues as media coverage of neuroscience innovation and the importance of public concerns and lay opinion; nonmedical use of pharmaceuticals for performance enhancement; and the discord between intuitive notions about consciousness and behavior and the scientific understanding of them.
Racine proposes a pragmatic neuroethics that combines pluralistic approaches, bottom-up research perspectives, and a focus on practical issues (in contrast to other more theoretical and single-discipline approaches to the field). [He discusses ethical issues related to powerful neuroscience insights into the mechanisms underlying moral reasoning, cooperative behavior, and such emotional processes as empathy.] In addition, he outlines a pragmatic framework for neuroethics, based on the philosophy of emergentism, which identifies conditions for the meaningful contribution of neuroscience to ethics, and sketches new directions and strategies for meeting future challenges for neuroscience and society.
Basic Bioethics series
About the Author
Eric Racine is Director of the Neuroethics Research Unit at the Clinical Research Institute of Montreal and Assistant Research Professor at the Clinical Research Institute of Montreal. He also holds appointments at the University of Montreal (Medicine, Preventive and Social Medicine, and Bioethics) and McGill University (Neurology and Neurosurgery and Biomedical Ethics).
Table of Contents
- Pragmatic Neuroethics
- Basic Bioethics
- Arthur Caplan, editor
- A complete list of the books in the Basic Bioethics series appears at the back of this book.
- Pragmatic Neuroethics
- Improving Treatment and Understanding of the Mind-Brain
- Eric Racine
- The MIT Press
- Cambridge, Massachusetts
- London, England
- Massachusetts Institute of Technology
- All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from the publisher.
- For information about special quantity discounts, please email firstname.lastname@example.org
- This book was set in Sabon by Westchester Book Group. Printed and bound in the United States of America.
- Library of Congress Cataloging-in-Publication Data
- Racine, Eric, 1976–
- Pragmatic neuroethics : improving treatment and understanding of the mind-brain / Eric Racine.
- p. ; cm. — (Basic bioethics)
- Includes bibliographical references and index.
- ISBN 978-0-262-01419-9 (hardcover : alk. paper) 1. Neurology—Moral and ethical aspects. 2. Neurosciences. I. Title. II. Series: Basic bioethics.
- [DNLM: 1. Neurosciences—ethics. 2. Behavior—ethics. 3. Bioethical Issues. 4. Morals. 5. Neurology—ethics. WL 100 R121p 2010]
- RC343.R16 2010
- 10 9 8 7 6 5 4 3 2 1
- Preface ix
- Acknowledgments xv
- 1 Salient Challenges in Modern Neuroethics 1
- 2 Reviewing Past and Current Neuroethics
- Definitions, Attributes, and Perspectives 27
- 3 Pragmatic Naturalism in Bioethics 53
- 4 Neuroethics
- Exploring the Implications of Pragmatic Naturalism 71
- 5 Public Understanding of Neuroscience Innovation and Emerging Interpretations of Neuroscience Research 97
- 6 Enhancement of Performance with Neuropharmaceuticals
- Pragmatism and the Culture Wars 121
- 7 Disorders of Consciousness in an Evolving Neuroscience Context 139
- 8 Communication of Prognosis in Disorders of Consciousness and Severe Brain Injury
- A Closer Look at Paradoxical Discourses in the Clinical and Public Domains 161
- 9 Social Neuroscience
- A Pragmatic Epistemological and Ethical Framework for the Neuroscience of Ethics 179
- 10 Conclusion
- Neuroethics and Future Challenges for Neuroscience, Ethics, and Society 215
- References 223
- Index 255
- Series Foreword
- I am pleased to present the twenty-seventh book in the series Basic Bioethics. The series presents innovative works in bioethics to a broad audience and introduces seminal scholarly manuscripts, state-of-the-art reference works, and textbooks. Such broad areas as the philosophy of medicine, advancing genetics and biotechnology, end-of-life care, health and social policy, and the empirical study of biomedical life are engaged.
- Arthur Caplan
- Basic Bioethics Series Editorial Board
- Joseph J. Fins
- Rosamond Rhodes
- Nadia N. Sawicki
- Jan Helge Solbakk
- Pragmatic Neuroethics is a book based on the reasonable hope that if clinicians and researchers from various disciplines work together in collaboration with different stakeholders, the chances of making a difference for patients suffering from neurological and psychiatric disorders can be increased. It relies on the belief that ethics is a crucial part of this endeavor, and that ethics, the search for the good and for what Aristotle called moral excellence, is inherently part of social and medical acts aiming to alleviate suffering, pain, and daily difficulties for patients. This view is at the heart of this book and of what I describe as “pragmatic neuroethics,” a view of bioethics influenced by various thinkers that emphasizes the pluralistic nature of ethics and society and the value of interdisciplinary collaboration and research to further knowledge and institute beneficial practice changes in healthcare, science, and society.
- The need for an interdisciplinary and collective response to ethical challenges in neuroscience and clinical care—neuroethics—has surfaced in the past years in response to important social, medical, and scientific changes. In many developed countries today, as illustrated by data of the World Health Organization, the combined “health burden” of neurological and mental health disorders matches and even surpasses that of any cluster of health conditions (World Health Organization 2001, 2006). Developing countries are spared neither from this prevalence of neuropsychiatric conditions nor from issues of stigma associated with mental illness and the need for better treatments for neurological disorders. The term “health burden,” often measured in days of lost productivity, may seem overly administrative. Nonetheless, it is a convenient way to illustrate the costs of caregivers without appropriate support and resources; stigma and discrimination; lives that are shattered by illness and isolated suffering; lack of research efforts; and, in some unfortunate cases, suicide. Today, almost everyone can look around and identify, if not themselves, a friend or relative that has faced not only a mental health or neurological problem but the challenges of being respected as a person and finding the internal resources to carry forward. These are the familiar stories of depressed friends or colleagues who never came back to work after falling ill and elderly parents coping with dementia. In proportion to other serious illnesses, diseases of the brain and mind now represent one of the greatest—and still increasing—public health burdens faced by both higher- and lower-income nations.
- This book presents neuroethics as an unprecedented opportunity to integrate healthcare neurospecialties such as neurology, psychiatry, neurosurgery, the humanities, neuroscience research, social science, and allied healthcare professions to tackle the emerging challenges in neuroscience and to improve patient care. There are signs that we are making some headway. Scientists, governments, advocacy groups, and public health authorities are intensely pursuing research to address the causes and consequences of neurological and psychiatric disease and to search for “cures.” The clinical translation of neuroscience is not straightforward, and as neuroscience research progresses and strives to improve clinical practices and public understanding, many scientific unknowns make it difficult to produce practical clinical neuroscience applications. In addition, once some clinical changes are introduced, the pluralistic nature of contemporary societies means that not everyone will always unanimously agree on what is an “advance” or “progress.” For example, if we could know with more accuracy our future risk of developing depression or Alzheimer’s disease—based on a combination of structural brain measures, brain activity patterns, and neurogenetic testing—would everyone feel that it is in their best interest to know? What about the potential of neuropharmacology to generate medicines that can not only treat illnesses but also improve cognitive function in the healthy? And when are scientific advances dealing with complex and sensitive issues or health conditions such as disorders of consciousness ready to be shared with the broader public? Neuroethics signals that promising advances are surfacing but, as they percolate to healthcare and public stakeholders, questions surface about how new insights and new interventions will find their proper place in society to serve individuals and the public good.
- Neuroethics, alongside other initiatives, has surfaced to tackle head on some of the challenges created by advances in neuroscience. However, to date, there have been few theoretical perspectives on this new field and scarce in-depth discussion about its nature and scope. In response, this book provides such a perspective as well as examples of research that attempts to bridge different disciplines to provide frameworks for elucidating and attending to important neuroethics issues. These include, for example, the increasing use of neuropharmacology to enhance performance and the incursion of functional neuroimaging in the world of the humanities and social sciences beyond conventional clinical neuroscience research. I hope that readers will find this book enlightening and stimulating, enough so to encourage reflection, action, or research that will contribute to meeting the broad ethical, scientific, medical, and social challenges that we collectively face.
- Pragmatic Neuroethics pursues a number of goals: (1) to thoroughly review diverging perspectives within neuroethics and provide a constructive critical analysis of the latest literature; (2) to provide a consistent view of the field with compelling arguments that yield a theoretical approach to tackling several problems within neuroethics; (3) to address several key neuroethics issues using empirical research data and a pragmatic approach; and (4) to identify future challenges for neuroscience and society and discuss possible directions for the field of neuroethics. The limitations of this book include the focus on some salient challenges to the detriment of others as well as perspectives that reflect my training in bioethics, social science, and philosophy. For example, legal issues related to neuroscience are not addressed, and I will be the first to admit that many more issues, especially clinically relevant ones, such as stigma, neurodegenerative disease, and aging, pose huge challenges to society. Further, given the range of topics, some will require more attention in the future.
- Pragmatic Neuroethics is divided in two parts. The first section, chapters 1 through 4, reviews recent neuroethics scholarship, provides background on neuroethics, and introduces pragmatism and pragmatic neuroethics. The second section, chapters 5 through 9, presents a series of essays on salient topics in neuroethics such as decision making in disorders of consciousness; public understanding of neuroscience; and policy approaches to “cognitive enhancement.”
- Chapter 1 (“Salient Challenges in Modern Neuroethics”) provides a thematic overview of neuroethics and explains some of the key areas currently under discussion. By gaining acquaintance with these topics, the reader should get a clear sense of why modern neuroethics has surfaced to systematically examine emerging challenges. Chapter 2 (“Reviewing Past and Current Neuroethics: Definitions, Attributes, and Perspectives”) analyzes some early definitions of neuroethics and identifies some distinct views of the field. A review of neuroethics attributes and the ethical, legal, and social issues associated with it in peer review literature, on the Internet, and in print media gives an overall sense of how the field has been characterized in formal academic definitions and beyond. Chapter 3 (“Pragmatic Naturalism in Bioethics”) presents and discusses different waves of naturalism in bioethics, including how neuroethics has reinitiated discussions on the relationship between the biological sciences and the humanities. This chapter argues that bioethics in itself is a form of pragmatic naturalism as illustrated by the field’s commitment to interdisciplinary collaborations and its practical focus. Finally, chapter 4 (“Neuroethics: Exploring the Implications of Pragmatic Naturalism”) explores the implications of pragmatic naturalism by addressing several controversies surrounding neuroethics. It concludes by highlighting some of the characteristics of pragmatic neuroethics, such as the integration of pluralism, bottom-up research approaches, and a focus on practical issues that distinguish this approach from other, more theoretical or more monodisciplinary views of the field.
- The second part of this book presents a series of essays that are nourished by both the background material and the theoretical framework of pragmatic neuroethics laid out in chapters 1 through 4. Chapter 5 (“Public Understanding of Neuroscience Innovation and Emerging Interpretations of Neuroscience Research”) highlights the importance of public understanding from a pragmatic perspective in order to take into consideration not only expert opinions about ethics in neuroscience but also public concerns and emerging lay interpretations of neuroscience research. This chapter discusses various forms of media coverage of neuroscience innovation. Chapter 6 (“Enhancement of Performance with Neuropharmaceuticals: Pragmatism and the Culture Wars”) stems from a context of increasing prevalence and salience of nonmedical uses of neuropharmaceuticals for performance enhancement. This chapter examines critically some of the assumptions behind the conservative and liberal moral-political approaches to this issue and makes the case from a pragmatic standpoint for the recognition of pluralism and for approaches that minimize harm, promote autonomy, and urge considerations for the public good. Chapter 7 (“Disorders of Consciousness in an Evolving Neuroscience Context”) provides background information and some discussion of different clinical conditions such as the vegetative state and the minimally conscious state, called collectively disorders of consciousness, in an evolving neuroscience context that challenges some assumptions about these disorders. Chapter 8 (“Communication of Prognosis in Disorders of Consciousness and Severe Brain Injury”) builds on the material presented in chapter 7 to discuss in more detail why there are lingering sources of confusion in disorders of consciousness. Specifically, I argue that there is a strong tension at work between, on the one hand, intuitive notions about consciousness and behavior and, on the other hand, scientific understanding and medical language describing consciousness and behavior. Chapter 9 (“Social Neuroscience: A Pragmatic Epistemological and Ethical Framework for the Neuroscience of Ethics”) builds on the naturalism inherent to pragmatic naturalism and discusses the possibility that neuroscience provides powerful insights into the mechanisms underlying moral reasoning, cooperative behavior, and emotional processes such as empathy. This chapter briefly introduces social neuroscience and the neuroscience of ethics and highlights some potential benefits and misunderstandings created by this area of research. It then presents a pragmatic framework based on the philosophy of emergentism. This framework yields conditions and guideposts for the meaningful contribution of neuroscience to ethics. This emergentist and pragmatic framework also debunks common arguments against the introduction of neuroscience research into ethics as well as overstated promises. The conclusion of
- Pragmatic Neuroethics (“Neuroethics and Future Challenges for Neuroscience, Ethics, and Society”) revisits some major issues discussed in this book and sketches recommendations and strategies for moving ahead.
- I hope that readers of this book will enjoy these neuroethics contributions. It is also my hope, even though I realize much still needs to be done, that each chapter will stimulate reflection, action, and ideas for research that embrace pragmatic goals while remaining open to genuine dialogue in the search for collaborative and practical solutions.
- Although it bears the signature of one man, this book, which captures some of my basic opinions, would have been absolutely impossible without the support of many colleagues and students. This is an opportunity for me to acknowledge the help and support of colleagues, family, and friends who have directly or indirectly inspired and supported my work in the last years.
- I would like to sincerely thank Nicole Palmour for reviewing this manuscript on several occasions and providing constructive and helpful comments. I want to thank former and current trainees and assistants of the Neuroethics Research Unit: Amaryllis Ferrand, Cynthia Forlini, Constance Deslauriers, Emily Bell, Ghislaine Mathieu, Bruce Maxwell, William Affleck, Zoë Costa-von Aesch, Marie-Josée Dion, Marta Karczewska, Matthew Seidler, David Bouvier, David Risse, Catherine Rodrigue, Lila Karpowicz, and Danaë Larivière-Bastien. Their work and presence have inspired me along the way and are truly appreciated. My work reflects part of the ongoing daily conversations and exchanges I have had with them, and I am immensely indebted to them.
- I consider myself privileged to have received the mentorship of outstanding individuals along the years. I have been fortunate to cross paths with senior scholars who possess extraordinary energy, creativity, and commitment. I would like to thank in particular Judy Illes, Hubert Doucet, and Bartha Knoppers for their generous time, ongoing support, and encouragements. Nothing can replace the mentorship and advice a young scholar receives from senior colleagues or the intellectual exchanges that occur within collegial and respectful environments. I would like to thank particularly Walter Glannon for his helpful guidance throughout this project, James Bernat for helpful comments on this manuscript, and an additional anonymous reviewer.
- The idea for writing this book originates partly from the days of my postdoctoral fellowship at the Stanford Center for Biomedical Ethics (SCBE). I would like to thank accordingly the leadership of the SCBE, in particular David Magnus, Henry Greely, and Mildred Cho, for support and the staff members (Anne Footer, Paula Bailey, Joyce Prasad, and Shobha Kumar) who helped me in many different ways to make this a successful journey. I want to thank the students who worked with me on various projects at the SCBE, including Sarah Waldman, Adri Van der Loos, Ofek Bar-Ilan, Stacey Kallem, Neil Mukhopadhyay, Allyson Mackey, Vivian Chau, Rakesh Amaram, Marisa Gallo, and Tessa Watt. I am indebted for their assistance in numerous research projects, and the exchanges I have had with them are marked in my past and present and will remain with me for the future.
- Pragmatic Neuroethics materialized during a visiting fellowship at the Brocher Foundation in August 2007, where I had the privilege to put on paper the project for this book. The beautiful and inspiring settings provided by the foundation’s location on the shores of Lake Geneva and the friendly exchanges with colleagues helped me prepare the proposal and nourished this project as it unfolded. I would like to thank the leadership of the Brocher Foundation, in particular Cécile Caldwell Vulliéty, and the friendly staff, especially Raji Sultan for his kind assistance. I would also like to acknowledge the support of colleagues I met during my enjoyable stay there (Anthony Mark Cutter, Thomas Douglas, Bert Gordijn, Rouven Porz, Michael Selgelid); they made this a remarkable and inspiring experience for me and my family members (Nathalie, André-Anne, Gabrielle, and Amélie). The foundation’s generous support for the publication of this book deserves special recognition.
- During the writing of this work and the work that preceded it, I received fellowships, awards, and grants from several agencies, including the Social Sciences and Humanities Research Council, the Fonds de la recherche en santé du Québec, the National Institutes of Health (grant awarded to Judy Illes), the Greenwall Foundation (grant awarded to Judy Illes), the Canadian Institutes of Health Research (Ethics Office; Institute of Neurosciences, Mental Health and Addiction; Institute of Human Development, Child and Youth Health), the CIHR-funded States of Mind Network (Françoise Baylis), and the CIHR-funded Pediatric Neuroimaging Ethics Network (Jocelyn Downie). The support from these agencies and from various peer communities has made much of the work underlying this book possible.
- I am grateful for the support from the unique Institut de recherches cliniques de Montréal (IRCM), especially Louis-Gilles Durand, who has been an invaluable source of inspiration and advice in the past three years. Jeannine Amyot’s impressive administrative skills and commitment to supporting the Neuroethics Research Unit need to be underscored and acknowledged. I thank all my IRCM colleagues who have provided feedback on material presented in this book and who believe in the legacy of Jacques Genest, the founder of the institute, who was committed early in the 1970s to creating the first Canadian Bioethics Center. The example and vision he has set to bridge research, healthcare, and ethics in the service of humankind will be with us for decades and hopefully centuries. Thanks to Claudia Jones and Nicole Campeau at the library, and to the IRCM leadership, in particular its director, Tarik Möröy, for his confidence in and ongoing support of this project and others.
- Material in this book has been presented at several occasions during seminars, talks, and scientific congresses. I would like to acknowledge the feedback given by audiences and colleagues at the University of Tokyo, the University of Delaware, Uppsala Universitet, Université Laval, Université de Montréal, the University of Minnesota, McGill University, Stanford University, the University of Toronto, Universidade do Estado do Rio de Janeiro, the Alden March Bioethics Institute, the Montreal Neurological Institute, Université du Québec à Montréal, the National Research Council of Canada, the Jewish Rehabilitation Hospital, the University of Pennsylvania, the University of Alberta, the University of Western Ontario, York University, Universidade Federal de Rio de Janeiro, and Concordia University. I am also indebted to audiences at various scholarly meetings, including the Canadian Bioethics Society, the American Society for Bioethics and Humanities, the Society for Neuroscience, the International Conference in Clinical Ethics, the Society for Social Studies of Science, the Canadian Association for Neuroscience, the International Association for Bioethics, Association Francophone pour le Savoir, the Neuroethics Society, the International Academy of Law and Mental Health, the American Philosophical Association, and the International Society of History, Philosophy, and Social Studies of Biology. I would like to thank students from the neuroethics seminars at Université de Montréal and at McGill University for stimulating exchanges in 2008 and 2009.
- Portions of chapters 1, 4, and 5 have previously appeared in E. Racine and C. Forlini, “Cognitive Enhancement, Lifestyle Choice or Misuse of Prescription Drugs? Ethics Blind Spots in Current Debates,”
- Neuroethics (2008).
- Portions of chapter 1 have previously appeared in E. Bell, G. Mathieu, and E. Racine, “Preparing the Ethical Future of Deep Brain Stimulation,”
- Surgical Neurology (2009).
- Portions of chapters 1 and 8 have previously appeared in E. Racine and E. Bell, “Clinical and Public Translation of Neuroimaging Research in Disorders of Consciousness Challenges Current Diagnostic and Public Understanding Paradigms,”
- American Journal of Bioethics 8 (2008): 13–15.
- Portions of chapters 2 and 4 have previously appeared in E. Racine, Comment on “Does It Make Sense to Speak of Neuroethics?”
- EMBO Reports 9 (2008): 2–3.
- Portions of chapter 3 have previously appeared in E. Racine, “Which Naturalism for Bioethics? A Defense of Moderate (Pragmatic) Naturalism,”
- Bioethics 22 (2008): 92–100.
- Portions of chapters 4 and 9 have previously appeared in E. Racine, “Interdisciplinary Approaches for a Pragmatic Neuroethics,”
- American Journal of Bioethics 8 (2008): 52–53.
- Portions of chapters 6 and portions of the conclusion have previously appeared in E. Racine, O. Bar-Ilan, and J. Illes, “fMRI in the Public Eye,”
- Nature Reviews Neuroscience 6 (2005): 159–64.
- Portions of chapters 6 have previously appeared in E. Racine, O. Bar-Ilan, and J. Illes, “Brain Imaging: A Decade of Coverage in the Print Media,”
- Science Communication 28 (2006): 122–142.
- Portions of chapter 8 have previously appeared in E. Racine, R. Amaram, M. Seidler, M. Karczewska, and J. Illes, “Media Coverage of the Persistent Vegetative State and End-of-Life Decision-Making,”
- Neurology 71 (2008): 1027–1032.
- Portions of chapter 9 have previously appeared in E. Racine and J. Illes, “‘Emergentism’ at the Crossroads of Philosophy, Neurotechnology, and the Enhancement Debate,” in J. Bickle, ed.,
- Handbook of Philosophy and Neuroscience , New York: Oxford University Press (2009): 431–453.
- I want to acknowledge the outstanding support of MIT Press, especially that of Clay Morgan, Laura Callen, Katherine Almeida, Susan Clark, and Meagan Stacey, and the editor of the Basic Bioethics Series, Arthur Caplan. Their encouragement and understanding are tremendously appreciated. Thanks to Nathalie for years of ongoing support and belief in the importance of this project and my scholarly work. I look forward to the future and seeing the lives of our children unfold. Thanks to my parents and my family members who encouraged me and who will for my life long be a daily source of inspiration.
- This book is dedicated to those who have suffered and still suffer in silence.
"Valuable for serious scholars of the history of bioethics and the relationships between media and science."—Choice
"A wide-ranging exploration of neuroethics by one of the field's leaders. Racine's book reflects his commitment to clinical bioethics as well as his broad perspective on the field. He has given us a wonderful account of 'pragmatic neuroethics.'"—Martha J. Farah, Director, Center for Neuroscience and Society, University of Pennsylvania
"Pragmatic Neuroethics is an important contribution to the growing literature on the ethical questions raised by clinical applications of the new brain research. Its sophisticated philosophical and scientific analysis is based on impeccable scholarship. Highly recommended."—Jonathan D. Moreno, David and Lyn Silfen University Professor and Professor of Medical Ethics and of History and Sociology of Science, University of Pennsylvania
"Progress in neuroscience is advancing human self-understanding and creating hope for the treatment of devastating neuropsychiatric diseases. At the same time, this progress has raised a host of significant issues for ethics and policy. Eric Racine provides an intelligent and lucid overview of the emerging field of neuroethics that I hope will be widely read."—Steven E. Hyman, Provost of Harvard University and Professor of Neurobiology, Harvard Medical School