Brains: the ethics of new technologies

Last week the Nuffield Council on Bioethics published their latest report, Novel Neurotechnologies: intervening in the brain. Emma Rhule attended the launch. 

EEG cap – used during transcranial magnetic stimulation

Stroke is the leading cause of disability within the UK and an increasing number of people are affected by brain disorders such as Parkinson’s disease and dementia; the need for interventions that help people with neurological and mental health conditions are undeniable. Last year, the Nuffield Council on Bioethics established a working group to explore the ethical, regulatory and societal impacts of new technologies that interact with the brain.

With such a broad remit, the Working Group consisted of experts from a range of disciplines including neuroscience, law, ethics and cybernetics, chaired by Professor of Philosophy, Tom Baldwin. The resulting report, Novel Neurotechnologies: intervening in the brain, explores the potential benefits and risks of contemporary technologies. In addition to a thorough exploration of the literature and current research, the Working Group also undertook a public consultation to which over 60 organisations and individuals responded.

Neurotechnologies are any technologies that aid or impact our understanding of the brain from imaging techniques through to pharmaceuticals. The particular focus of this report is physical devices or techniques that interact directly with the brain, many of which are still undergoing research.

Super stimulation

The report considers four technologies: Transcranial brain stimulation; Deep brain stimulation; Brain-computer interfaces and neural stem cell therapies. Most of these technologies are very much still at the research stage – at least in the UK. Transcranial brain stimulation, the least invasive of the four, is currently being explored as a treatment for depression and addiction. The potential use of brain-computer interfaces to enable amputees to control prosthetic limbs is under investigation while neural stem cell technologies seek to repair damage to the brain caused by stroke or degenerative conditions like Alzheimer’s disease.

In contrast, deep brain stimulation (DBS) is the only one of the four technologies currently used to treat patients. Involving the use of electrodes implanted directly in to the brain and powered by battery packs hidden under the skin, DBS is regularly used to treat patients with movement disorders such as dystonia and Parkinson’s disease. Developments in brain imaging such as functional magnetic resonance imaging, fMRI, have enabled researchers to pin point which parts of the brain are directly responsible for many of these involuntary muscle spasms. This allows an electrical current to be passed directly over a specific part of the brain, for instance, stimulation of the thalamus improves tremor control and walking patterns in people with Parkinson’s disease, while stimulation of the globus pallidus relieves the sustained muscle contractions experienced by people with dystonia.

With the first operation to implement DBS taking place over 20 years ago, this may not seem like a very ‘novel’ technology. However, it’s inclusion in the report is significant for two reasons. First, many people are justifiably nervous of physical interventions into the brain. The heart-breaking stories of people in vegetative states after the widespread use of lobotomies during the 1940s to 1960’s have left enduring cultural memories. The successful use of DBS in movement disorders proves that with a better understanding of the brain, such operations can positively impact on a patient’s life with minimal side effects.

Secondly, it is the recent research exploring the use of DBS for psychiatric disorders that was of particular interest to the Working Group with respect to novelty. While most of us would agree that mental illnesses are intimately connected to the workings of the brain, unlike with movement disorders, there is little hard evidence allowing researchers or doctors to identify a specific area that is responsible for a specific illness. Professor Maria Fitzgerald, a developmental neurobiologist and member of the Working Group argued that without knowing exactly where to place the electrodes for DBS it is essentially a guessing game – one that can cause unforeseen and unwanted consequences for the patient.

Report recommendations

Unforeseen consequences lie at the heart of the ethical issues surrounding the development and use of novel neurotechnologies, especially as we still don’t know or understand the mechanisms underlying how some of these technologies actually work. While that is not a reason in itself not to use them – we don’t know exactly how some commonly used drugs work either- it does raise concerns about the long term risks of their use. Furthermore, many patients with neurological disorders are in desperate situations. The report stresses that researchers and clinicians must make sure that they and their families are not exploited.

One way in which the authorities are trying to minimise the risk of exploitation is through stringent regulation. However, there is a fine balance between ensuring safety and hampering development and innovation with red tape. Differences in the regulatory pathways of the technologies discussed gives rise to different challenges. Devices, such as those used for brain-computer interfaces are regulated as medical devices whereas neural stem cell therapies are classed as advanced therapeutic medicinal products. This means that the latter must undergo clinical trials, proving not only that they are safe but that they actually work. Medical devices only have to prove safety and performance, for instance, does a transcranial magnetic stimulator produce a magnetic field, with no efficacy requirements. The flip side of a heavily regulated environment in the UK, as Prof. Nikolas Rose pointed out, is the stimulation of unregulated practices in other countries. This could encourage health tourism, placing already vulnerable patients in a worse situation.

There is already evidence of people exploiting these technologies for non-medical purposes, for example the use of transcranial brain stimulation to improve learning and memory skills. As previously mentioned, little is known about the long term effects of these technologies and there are particular concerns about the potential impact of use in children. Many of the concerns expressed are similar to those aired in the current debate surrounding cognitive enhancing drugs, especially issues around accessibility and equity.

Although there is much excitement about the future of novel neurotechnologies, caution is needed to avoid exaggerated reports of their potential. The report highlights a number of examples where modest experimental results have been overstated, example- ‘Paralysed man’s mind is “read”’. The report cautions that it is important to prevent ‘hype, which can creep in at any stage from researcher through to newspapers, of these novel technologies. The fear is that such hype both undermines public trust in this area of science and can also give patients unrealistic expectations.

With many of these technologies still in their infancy, the council’s timely report represents the start of a process to create an ethical, regulatory and societal environment in which such technologies are encouraged and helped to develop whilst minimising harm to patients and the wider public.