Empowering brain science with neuroethics.

1294 www.thelancet.com Vol 376 October 16, 2010 More than two decades ago I was a young researcher in a laboratory in San Francisco, California, using multichannel electroencephalography (EEG) to study the functions of the brain. One of our experiments was on the eff ects of fatigue on memory, and we were interested to learn how the brains of elite professionals whose work required extraordinarily long periods of wakefulness and attentiveness diff ered from people with more ordinary wake-sleep schedules. Fighter pilots were our target group, and each received an MRI that provided the structural map on which we would overlay the functional signals once we had analysed them. In one case of a fi t young man, the MRI suggested a brain anomaly of potential medical signifi cance. As non-physician researchers, we were ill-equipped to deal with such an incidental fi nding. We were not trained to read MRI, did not formally have a physician partner who could, and had not put in place a protocol for seeking the advice of one. What we did know was that if we disclosed our suspicion, whether the fi nding turned out to be a real health threat or a false alarm, the career of this pilot would probably end there and then. We remained silent. That was the 1980s. Fast forward to the present. Neuroethics has established itself as a discipline dedicated to tackling tough practical questions like those of unexpected brain anomalies in research and has been moving age-old debates about mind and brain towards modern theoretical discussions about the understanding of human behaviour enabled by advances in neurosciences. In unusually interdisciplinary collaboration between neuroscientists and scholars from ethics, philosophy, law, and others who focus on the implications and applications of science, consideration of the ethical, legal, social, and policy challenges of neuroscience have been explicitly brought forward. These initiatives are allowing neuroethicists to think about topics well known to other pursuits within the domain of research and bioethics, such as consent, confi dentiality, and disclosure, and others unique to the brain, such as personhood, authenticity, agency, and mental states. Through this wide lens, the societal implications both of laboratory studies and clinical neuroscience studies have come into view. Issues of personhood and authenticity, for example, have become hotly debated among neuroethicists as pharmaceuticals developed for improving mental health disorders, sleeping disorders, or attention disorders in children are now being consumed at high rates as off -label “cognitive enhancers” to boost mood, memory, and alertness. If these drugs, or substances like oxytocin, become the Viagra of daily functioning and create new benchmarks for productivity, wakefulness, and emotional love, what will happen to the fabric of society and the character of our interactions with one another? Are these altered states a genuine refl ection of a new and improved “me” or “we”, or some transient drug-induced condition that thoroughly confounds what we inherently value? Will we be coerced into conforming to a wave of drug intervention in the ever expanding, do-ityourself, self-help world? The race for cognitive enhancers poses questions of social justice as well. Will the opportunity gaps between those who can aff ord them and those who cannot be widened or narrowed? Will the safety of some be compromised as low-cost, poor-quality alternatives are acquired on the black market or on the unregulated internet? Moreover, what happens if enhancement by drugs becomes obsolete, only to be replaced by possibly more enduring, lower-maintenance forms of neurotechnological interventions, such as direct brain stimulation through implanted devices or with stem cells? Interlinked with these concerns is the ever-improving understanding of the neurobiology of behaviour for which questions about social policy and law come into play. For example, neuroscience has done much to explain how the adolescent brain is not fully developed and myelinated before the age of roughly 21 years, complementing readily made observations and fundamental intuitions about risktaking behaviour and notions of right and wrong in this age group. But given the diversity of people and their experiences The Art of Medicine Empowering brain science with neuroethics