Neuroscience Advances Force New Thinking on Ethics

Advances in neuroscience and genetics promise new ethical challenges for psychiatrists and for the teaching of ethics in psychiatry training programs.

So said past APA President Paul Appelbaum, M.D., in a lecture at the annual meeting of the American Association of Directors of Psychiatric Residency Training last month in New Orleans.

Appelbaum told training directors that the traditional subjects of psychiatric ethics lectures—confidentiality, boundary violations, and informed consent—will not encompass the ethical dilemmas posed by such emerging technologies as deep brain stimulation and stereotactic brain tissue ablation, new options in genetic testing, and the likely availability of drugs for cognition and other forms of therapy for personal“ enhancement.”

“We need to help our residents understand the challenges that exist now and will exist in the foreseeable future,” Appelbaum said. “My impression is that some programs do a very good job of this and others do not. But ethics today tends to be focused on traditional issues, so we talk to our residents about confidentiality, boundaries, and consent.

“These are all extremely important, but they are not enough,” he said. “When I see a residency program where trainees have three to five lectures on ethics in four years of training, I know we are not training our residents adequately for the challenges ahead.”

Appelbaum is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and director of the Division of Psychiatry, Law, and Ethics in the Department of Psychiatry at Columbia University College of Physicians and Surgeons.

He described two broad areas of emerging neuroscience that will change the way psychiatrists and patients think about ethics. The first consists of advances in understanding the brain, including the ability to predict the risk for mental disorder; new research on understanding moral behavior; and the potential to use new techniques nonconsensually for assessing the brain—such as in the detection of deception.

The second broad area of ethical challenge Appelbaum discussed consists of the emerging ability to alter and manipulate the brain, the potential for cognition-enhancing pharmaceuticals, and the coercive use of interventions that alter brain function.

Some of these areas may exceed the expertise of faculty and training directors familiar with the traditional ethical categories in psychiatry and will require ethics teachers to team up with neuroscientists.

“Many ethics teachers don't come from science backgrounds,” Appelbaum said. “It's a little beyond their comfort zone. If they can't stretch those comfort zones, they may have to try other approaches, including team teaching with neuroscientists.”

But he said the ethical dilemmas of tomorrow still yield themselves to the models of investigation used for traditional ethical issues. “It is still a matter of balancing competing goods and competing harms,” he said. “The best way to do this is through case-based examples that residents can struggle with to demonstrate the processes in determining what should be—or what ought to be—and what is likely to result from a particular choice.”

Appelbaum said imaging techniques are being developed that may someday offer a neuroanatomical “lie detector.” And new technologies such as deep brain stimulation, brain tissue ablation, and transcranial magnetic stimulation are offering highly invasive procedures for peering into and altering the brain.

Pharmaceutical companies are working on drugs to improve cognition and attention for patients with schizophrenia. In time, memory- and cognition-enhancing drugs may be available to nonpatients as well.

But more immediately, it is the expanding knowledge of the human genome and the relationship of genes to mental illness that are opening one of the most intriguing and potentially problematic areas for psychiatric ethics.

Appelbaum cited a study by DeLisi and Bertisch in the January 5, 2006, American Journal of Medical Genetics Part B: Neuropsychiatric Genetics showing that a majority of patients and clinicians would seek or recommend genetic testing for risk of schizophrenia if there were a genetic test that could prove even a small percentage risk for schizophrenia.

In that study, a written questionnaire about genetic testing was distributed to registrants at the 2004 World Congress of Psychiatric Genetics and was mailed to clinical psychiatrists practicing in New York City and families who have multiple family members with schizophrenia. Of the 274 individuals who responded (162 researchers, 64 clinicians, and 48 family members), more than 83 percent of the families would want to be tested if a test were available.

Fifty-six percent of the family members would want prenatal testing, as would 52 percent of the clinicians. A quarter of the researchers would favor it.

Although the study did not report whether people would opt for abortion, the substantial number of family members and clinicians who would seek out or recommend prenatal genetic testing implies that the option would likely be considered.

“That's a significant number of people who might be willing to abort a pregnancy [with] less than a 2 percent chance of producing a child with schizophrenia,” Appelbaum said.

One hundred percent of the clinicians in the survey also thought that adoption agencies should inform families about a family history of schizophrenia. Yet Appelbaum wondered about the possible creation of a“ genetically tainted” cohort of unadoptable children should a genetic test be available to determine even a small risk of schizophrenia.

“How will we balance that risk against the right of families to know if there is a risk?” he asked. “When the information is available, the pressure to acquire it is almost irresistible.”

Today, a focus of genetics research in psychiatry is on the interaction between genes and environment in the risk for mental illness. There, too, the ability to predict risk could lead to some novel ethical choices for parents and clinicians.

Appelbaum cited the now much-referenced longitudinal study of the Dunedin, New Zealand, cohort exploring genetic control of production of the serotonin transporter, published in the July 18, 2003, Science by Avshalom Caspi, Ph.D., and colleagues.

They observed that the promoter region of the chromosome that determines the extent to which the serotonin transporter is transcribed can be either short or long; individuals with the short allele are more likely to experience depression in the first 26 years of life.

But what Caspi and colleagues also found was that the risk for depression was significantly increased only among people who had the short allele and had also experienced stressful life events.

“So if stress is the problem and avoiding stress is enough of a preventive intervention, does it warrant knowing whether or not your child is carrying the short allele?” Appelbaum wondered. “And what are the effects of protecting otherwise normal children from stress? Does that mean Johnny doesn't get to play Little League because his team might lose and that might be too much to bear?”

Moreover, Appelbaum said genetic tests for a wide range of conditions—including bipolar disorder and Alzheimer's—are now being marketed directly to individuals and offered for sale on the Internet.

“If you Google 'genetic test,' you will find tests for 20 or 25 disorders that companies are marketing right now,” Appelbaum said.“ So we as psychiatrists and our residents may not get to make the decisions about [whether to use these tests].”

The Delisi study, “A Preliminary Comparison of the Hopes of Researchers, Clinicians, and Families for the Future Ethical Use of Genetic Findings on Schizophrenia,” is posted at<www3.interscience.wiley.com/cgi-bin/abstract/112141685/ABSTRACT>. An abstract of the Caspi study, “Influence of Life Stress on Depression: Moderation by a Polymorphism in the 5-HTT Gene,” is posted at<www.sciencemag.org/cgi/content/abstract/301/5631/386>.▪