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About this author
Zack Lynch is author of The Neuro Revolution: How Brain Science Is Changing Our World (St. Martin's Press, July 2009).
He is the founder and executive director of the Neurotechnology Industry Organization (NIO) and co-founder of NeuroInsights. He serves on the advisory boards of the McGovern Institute for Brain Research at MIT, the Center for Neuroeconomic Studies, Science Progress, and SocialText, a social software company. Please send newsworthy items or feedback - to Zack Lynch.
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November 9, 2004

Neuroenablement - Beyond Therapy and Enhancement

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Posted by Zack Lynch

"The limits of our language are the limits of our world”

-Philosopher Ludwig Wittgenstein, 1921

Distinguishing the line between therapy and enhancement remains a contentious and difficult project. The debate revolves around a number of moral concerns, philosophical approaches, and practical safety issues as to the proper role of medicine, therapeutics, and values in society.

While most agree that a therapy can roughly defined as a treatment for a disorder or deficiency, which aims to bring an unhealthy person towards a healthier state of being, the term enhancement is so problematic that is has created grid-lock in ethical discussions of great practical importance.

No where was this more clear than in the keynote talks given by Leon Kass and Francis Fukayama at the American Society for Bioethics and Humanities conference in Philadelphia last week. The problem with these two terms is that they are not mutually exclusive, what might be considered healthy and normal for one person may not be for another.

So, what is normal? Clearly, every person enters the world with different natural endowments that fall along a distribution of emotional, cognitive and sensory capabilities. Those individuals with debilitating mental disorders or that exhibit extreme deficiencies in a particular capability relative to the general population are easily characterized into the therapy category.

Within the context of today's terminology the use of neurotechnologies by "healthy" individuals for “non-medical” purposes is currently defined as enhancement. However, this does not capture the actual intention and belief of most. This is why I am proposing a new model ethical model based on the concept of neuroenablement.

Without neuroenablement we run the risk of medicalizing most of human behavior and increasing the stigmatization associated with improving one's capabilities within one's right to pursue their individual definition of life, liberty and happiness.

As I have mentioned previously, in the minds of many, “enhancement” evokes artificiality, denotes a lack of worthy achievement, is characterized as “a perversion of medicine”, or even maligned as an unnatural shortcut. On the other hand, enablement projects images of empowerment, lifting the bottom up, and even addresses issues of fairness and social equity. Neuroenablement empowers people: it provides a way for people to leverage better tools for mental health to achieve desired results

As I will explain in future posts, the neuroenablement model will clarify ethical discussions, allow regulators to develop effective policies with respect to advancing neurotechnologies, and in the end promote human dignity. If you have a keen interest in this subject please feel free to email me with your thoughts.

Comments (8) + TrackBacks (0) | Category: Neuroethics


COMMENTS

1. Adam Fish on November 9, 2004 9:39 PM writes...

Zach,

Yes, that would be a striking improvement. Our current practice is medieval, 16th century. Totally disembodied. With the connective tissue being a pagan fear of flesh. Science incises out a precise hole in a black vacuum, 17th century. But remains superstitious of the body. Theocracy and Law interspeak, the court chambers and the spooky operating room share a lobby, 17th century. Practical policy emerges from experiments in democracy, 18 century. Electable Acts emerge from consortium, stagehands roll out the Senators, percolating from Constitutions, 19th century.

The last 400 years of social corporeal policy is consistent. The Medieval body image remains to instigate 20th century medical analogies for law. The culture of the fleece --the weighty soul, the body industry-- parades the mysterious polity.

On the body we place the stigmata of law, from which criminality emerges; or language, where the traps of categories vent; or science, where logical positivism fails; and god forbid, morality, virtue, ethics-- where the fundamentalists and evangelicals hold blow up dolls and flags in sports arenas. This leads to nation destroying, gay-bash, women debasing, prison packing social policy.

Our system of law excises tumors of differAnce.

Nevermind capitalizing on abnormality as if it were a natural gas deposit in a third world desert or an abandoned farmstead.

The enhancement model would reverse this maligned history of social iconography.

The use of enhancements to heal and excel.

But first we normalize madness.

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2. Wrye Sententia on November 10, 2004 12:55 PM writes...

Zack,

I agree that neuroenablement suggests better means to cope with gray areas left somewhere in between therapy and enhancement of brain function. Positive, life affirming, and individually tailored decision making in harmony with one's personal needs, biological profile, and life goals will enable better ways of coping with powerful neuropharmaceuticals and neurotechnologies.

In my own recent public exchange with Dr. Kass, I presented your concept of enablement to him and the audience, as a way to open up working ground in an otherwise muddled paralysis over diagnostic semantics. I then addressed, what previous commenter Mr. Fish gestures toward, the issue of historically-laden terminology wedded to social practices: the pursuit of happiness should be individually defined, and yet, in the *Beyond Therapy* Report from the President's Council on Bioethics, happiness is prescriptive.
[See: http://www.cognitiveliberty.org/news/Wryecbc2004_pic.htm ]

Anjan Chatterjee, at the UPENN Center for Cognitive Neuroscience has recently published an excellent article of related interest:

Chatterjee A. Cosmetic neurology: The controversy over enhancing movement, mentation, and mood. Neurology, 2004, 63: 968-974.
PDF at: http://wernicke.ccn.upenn.edu/~chatterjee/anjan_pdfs/CosmeticNeurology.pdf

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3. Conor Stack on November 10, 2004 8:04 PM writes...

Conor sent this via email and I thought I was too good not to post:

I'm a junior Neurobiology student at Cornell University. I've been reading your blog for a while now, and I find it most of the time very interesting and informative. The reason I'm e-mailing you has to do with your last post - Neuroenablement - and the question of normalcy that you brought up. I'm writing a mock magazine article for a communication class on ADHD, and I was wondering if I could have some of your thoughts on ADHD and the definition of normalcy. I have read your posts on ADHD and would be very grateful if you could respond to any or all of the questions I pose below.

People are sometimes critical of the diagnostic process of mental disorders like ADHD, that use seemingly unscientific checklists to determine if someone should be medicated. Do you feel these criticisms are warranted? How do you see neuroscience tackling this problem in the future?

Do you have any thoughts on the DataLex ADHD Indicator Report from Lexicor, which is being advertised as the first biological assessment tool for ADHD?

In your post, you say that without neuroenablement we run the "risk" of medicalizing behaviors. Where does the use use of Ritalin to make children more calm and attentive fall in this discussion? Should the definition of normalcy be broadened, given the increase in ADHD diagnosis over the past 10 years?

Just an aside on the topic of neuroenablement, right now I'm of the opinion that drugs that act on the mind are nothing more than tools (like a hammer in the hand analogy), and should be used as so. The danger, I think, is in using things that have side effects not completely known, or fully understood. You can always put a hammer down when you realize you have a splinter in your hand from it, but I think the mechanisms of drugs can be a lot harder to notice. Using drugs to make workers safer or more efficient should be a goal of neuroscience, but it is done responsibly only with proper understanding of what the drug is doing. That's just how I currently feel about it.

Once again, I enjoy your insights into the field neuroscience very
much. Thank you for any responses you can make to my inquiries.

-----
I sent Conor some info on this subject. I think he has a bright future.

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4. Anjan Chatterjee on November 11, 2004 11:16 AM writes...

Zack,

I like the notion of enablement, and agree that the therapy/enhancement division is problematic. It assumes clear notions of disease, and pragmatically it ignores the fact that research in therapy is likely to apply to enhancement.

In the paper on cosmetic neurology that I wrote recently, which Wrye Sententia kindly mentioned in her post, I suggest that a phrase used widely in clinical trials, “quality of life”, is more germane to these discussions than therapy or enhancement. Most of us want to improve the quality of our lives whether or not we are oppressed by disease. Quality of life seems similar to your notion of enablement.

But, problems remain. Even if we dispense with therapy and enhancements as a diversion, we are left with ethical issues that I at least find difficult. The four issues I mention in my paper focus on safety, character, distributive justice and coercion. Safety is a real concern as suggested by Mr. Stack. But, this concern does not cut as deeply as the others. There are no conflicts of interest in the desire for safety. Consumers, patients, physicians, drug companies, all want safer drugs and for purposes of discussion it makes sense to assume that drugs will continue to get safer.

The other three issues are more problematic. The issue of what constitutes character and what contributes to happiness is less clear. Having more tools at our disposal does not give us the wisdom to know what to construct. The issue of distributive justice also remains problematic. One might hope that enabling or improving the quality of life of those with less would level the playing field. My fear is that in practice such leveling is unlikely. The wealthy would have disproportionate access to pharmacological enablers.

Finally, the issue of coercion has not, in my view, received sufficient attention. Can we, as a society, require certain individuals (such as airline pilots) to take such drugs because the safety of others is at stake?

At the core of cosmetic neurology or neuroenablement are fundamental questions of what it means to be human and how individuals should create a just society. These questions have never had easy answers, and I suspect that neuroscience is poised to complicate things further.

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5. Lily Johnston on November 11, 2004 11:36 AM writes...

Your most recent post leaves me in a quagmire. Perhaps you can point me in the right direction?

It seems to me that there is an inherent problem in making available these enablements, assuming that they are not restricted to so-called therapeutic use. On the one hand, we cannot in good conscience only provide these drugs (etc.) to those who can afford them if they will also provide therapeutic (i.e. restoring a person to what most would consider an average functional range) effects to others who may not be able to afford them. However, if we provide access to all, there is no longer any semblance of “bringing the bottom up,” as you put it, because we simply shift the entire distribution, redefining in essence the average functional range.

Perhaps this is a poor analogy, but as plastic surgery has become more publicly accepted, the public has evolved an increasingly narrow and unattainable standard of beauty which consumes men and women across the country. Certainly we recognize the good that comes from reconstructing the face of a trauma victim, and today cosmetic/elective procedures are still only available to those who can afford them, but what do or should we say to an aspiring Hollywood actress who can’t get work because every director says she’s too unattractive? She is, indeed, below the average for her chosen profession. Many people would claim, though, that it was her choice to be an actress and that she could seek less demanding employment where she would be at or above average, even if it didn’t make her happy. Is there a good solution to this?

In the same vein, what is the appropriate response to a high school student who doesn’t have the grades to go to the best university, but will certainly have many choices at more modest institutions; do we enable him if he wants to go to the best school? If his parents want him to go to the best school? What are the implications of wide-spread enablement with niches of people who won’t participate for religious, moral or other personal reasons?

While individual examples and case studies illustrate specific questions in the enablement theory, I wonder more generally about the effect of these substances on our society as a whole. As we raise the standards for intelligence, behavior, and emotion, will it ever really be possible to meet these standards and feel accomplished, or will the drive toward “better living through chemistry” become confused with better brains through chemistry? Ironically, the very substances that have the potential to so drastically improve our capacities may also have the potential to make us more obsessed than ever with our own limitations.

I’m not arguing against neuroenablement, perhaps despite appearances to the contrary. I simply wish to have a better sense of the intricacies and implications of the model.

Thanks, as always, for a thought-provoking piece.

Sincerely,
Lily Johnston

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6. Michael Vassar on November 14, 2004 11:00 AM writes...

I think that the analogy with plastic surgery is misleading because appearance beyond average is primariliy a positional good, while intelligence is of social value. If everyone else became 1SD smarter, it would benefit me a great deal, even if I did not. If everyone became 1SD more attractive I would have difficulty competing for mates.
BTW, it's almost always going to be easier to use technology to lift the bottom than raise the top, so there's still an equalizing effect. By contrast, it is much easier for education to raise the top than for it to raise the bottom, so the much lauded benefits of education CREATE inequality.

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7. alfred on November 18, 2004 1:50 PM writes...

Congratulations Zack

I haven't seen this much in depth comment concerning your articles since I began reading your columns.

I find this unusual only because I thought the underlying concept of your column/blog was enablement. This isn't something new or out of context. Neurotechonology as the future is all about enablement.

I could be wrong though. Sometimes we read what we want to see/hear.

Concerning Anjan's comments:

"Finally, the issue of coercion has not, in my view, received sufficient attention. Can we, as a society, require certain individuals (such as airline pilots) to take such drugs because the safety of others is at stake?"

According to some news sources the military is already requiring pilots to take a form of "speed" to keep them alert and jacked for long periods of time during their repeated missions.

And according to your links to DARPA in previous posts the military is studying and using caffeine for the lower ranking servicemen.

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8. Kurt on November 18, 2004 10:05 PM writes...

I like the idea of enablement, because it has a very positive connotation that "enhancement" may not have.

Issues of safety and coercion are valid subjects of public debate. The others are not.

Issues of "character" and "happiness" are purely subjective and, therefor, cannot be legitamently discussed in the context of public debate. One person's concept of character and happiness may be completely different from someone else. These concept are individually specific. So, there is no objective basis of public debate on these matters.

Social justice is another issue. There are concerns that only the "wealthy" will be able to afford these enablements. There are two arguments against this:

One, medical treatments are currently expensive because of excessive regulation on the part of the FDA and the AMA's political power to control licensure as to who can be a "medical professional".

Two, neuroenhancements will improve productivity of those who use them. This increases economic productivity and growth as a whole which, in turn, will create more wealth and opportunity for people who do not use neuroenhancement. This is a well-known concept in economics called the Law of Comparitive Advantage and is taught in almost every economics class around the world.

The law of comparitive advantage simply states that if one person or group of persons are better at something than others, the well-being of the entire group of people increases absolutely, even if the advantaged group is superior in every capacity than the rest.

"Social justice" is often trotted out by unreconstructed leftists who do not understand economics.

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