Mahboobin 4:00 R05 EXPLORING BIOETHICS: SHOULD WE ENGINEER THE BRAIN? Christine Heisler (cnh27@pitt.edu) THE BREAKTHROUGH: BIOMARKER RESEARCH Before I knew that I wanted to pursue bioengineering, I realized that the effects of mental disorders were significant to me for several reasons. I have not personally experienced the effects of a neurological disorder, but several of my close friends live with depression and other mental disorders, and these conditions are indescribable. One of my closest friends has lived with depression for a few years and has recently been diagnosed with bipolar disorder. This person is one of the most brilliant, insightful, and inspiring people that I have ever had the privilege to encounter, and yet, this person is must live with the anxiety, loneliness, and mental pain of depression. Often, no matter how hard we try, no amount of encouraging words are able to bring a person out of his or her own mind. This is one of the most difficult obstacles that patients and their family and friends deal with- that they are practically helpless to solve the problem. However, as an aspiring bioengineer, I refused to believe that anyone should have to live with the horrors of depression, anxiety or any neurological disorder. Therefore, throughout my undergraduate studies, I made it a goal of mine to be a part of the solution to these neurological disorders. Now, through extensive research of biomarkers, a possible solution is within my reach, and I am inclined to seize this opportunity. However, I know I must proceed with caution and carefully analyze each code of ethics that govern bioengineering as a whole, and neuroscience, which is my current field of work. . Therefore, I will thoroughly consider each aspect of this case, and further my understanding of the implications of this solution. BACKGROUND: THE ROAD TO THE BREAKTHROUGH I have recently earned my Ph.D. from Pitt. After completing my undergraduate degree in bioengineering with a neuroscience minor, I decided to pursue graduate school to continue my neurological research and gain more in-depth knowledge on different neurological disorders and the root causes of these diseases. I am now working as the Research Coordinator in the neurological research department of UPMC. My team and I have been conducting research on several biomarkers in the brain that are linked to depression. My team is made up of four individuals: two who have an undergraduate and graduate degree in bioengineering from Pitt, and two who have an undergraduate and graduate degree in neuroscience from Pitt. We all have neurological research University of Pittsburgh, Swanson School of Engineering Submission Date 2015-11-03 experience. We are working specifically with two patients, Jane and John. Jane was diagnosed with depression one year ago. Our second patient, John, has been living with depression for over ten years. Both have similar symptoms commonly associated with depression, which include chronic mental pain, severe emotional highs and lows on a daily basis, and increased anxiety in several social situations. The effects of depression impair both of our patients greatly: they impair Jane in her academic and social aspects of college life, and they impair John in his marriage because even though he has a solid relationship in which his wife constantly reassures him, he lives in fear of losing connections with anyone who is close to him. Both individuals have tried several medications, simply hoping that they do not have an adverse reaction to these new doses. They have also tried cognitive behavior therapy, which has proven effective on certain patients. However, these treatments have proven ineffective for Jane and John. My team and I, who are all bioengineers by trade with extensive and varied knowledge in neuroscience, have done extensive biomarker research on Jane and John. We have discovered that the build-up of C-reactive proteins on the frontal lobe of these patients’ brains has had a negative result on the mental states of these two individuals. Even though these patients have been affected for different lengths of time, the amount of protein build up is similar and correlates to the negative effects of depression that both patients experience. Through extensive research and testing, my team has developed an injectable enzyme treatment that will destroy the C-reactive protein from this area of the brain. It is a relatively inexpensive procedure to perform and could be could be performed on several patients in the future. THE ETHICAL DEBATE Even though this is the breakthrough that my team and I have all been working for, we are currently faced with a few ethical dilemmas. The questions I must ask myself are: Should we go through with this procedure, taking into account all the possible consequences? Should it be repeated on other patients? Is this a viable option, or would engineering these patients’ brains alter their emotional state of being, not only their mental condition? Here is the overarching question that weighs heavily on my mind: Should we engineer the brain? As Brey asks in the article “Biomedical Engineering Ethics”, “Can humans still be held morally responsible for their behavior when their brain has been engineered by others to function in a certain way?” [1]. My job now is to consider all of these questions, weigh the options at hand, and decide if our procedure is viable to implement. Christine Heisler people affected by depression worldwide. Here, when we consider this BMES canon and consider all the people it will impact, we are faced with a vital question: Does the benefit of the relatively few amount of people who will gain use from our procedure outweigh the potential harm that it could cause many others? I believe that the potential help definitely outweighs the potential harm. Our procedure is indeed a step in the right direction, and if it can help even just a few people in a clinical setting, it has the potential to help several others, and therefore it should be implemented. I will continue to consult a variety of sources as I develop this initial opinion and contemplate the potential impacts of this procedure. WEIGHING THE OPTIONS There are several reasons that support the validity of our research and prove that we can ethically go through with this procedure. To start, as the Rules of Practice in the National Society of Professional Engineers ethical code states, “Engineers may express publicly technical opinions that are founded upon knowledge of the facts and competence in the subject matter” [2]. This canon is vital to the development of a new product or the implementation of a new procedure because there must be an extensive amount of information and research to back up the claims made by the product or procedure. If we predict that our procedure would completely eradicate all traces of the C-reactive protein and cure the patient of all symptoms of depression, this would be an invalid statement because we do not have the factual information required to prove it. However, through our extensive research and background knowledge in both bioengineering and neuroscience, my team has proven its competence in this subject matter. In addition, we have consulted with neurosurgeons and have performed repeated experiments to test the enzyme treatment. Therefore, we have fully acknowledged this canon and we can be confident that this procedure will lead to a significant decrease in the negative side effects associated with depression in patients with a similar concentration of C-reactive proteins. The NSPE code of ethics goes on to state that engineers have a professional obligation to “acknowledge their errors” and “not distort or alter the facts.” [2] As previously stated, my team and I do not assume that this treatment will work on every individual, because each brain is unique and complex. No single test will be able to predict the specific treatment of an individual, and no single procedure will be a ‘cure-all’. Also, there is no accurate way to predict how any patient would react to this procedure. In a similar way, because neuroimaging results may have a different meaning for each patient, there is no way that tests can determine potential for violence, as in the scenario called "Neuroimaging and Violence in the Educational Setting" [3]. For these reasons, we have tailored our treatment to specific individuals and biomarkers within these individuals. However, since this is such a target-specific procedure, it is not easily tested, nor is it easily applicable to many patients. As bioengineers, we must “consider the larger consequences of their work in regard to cost, availability, and delivery of health care”, as stated by the BMES code of ethics. [4]. Even though our procedure is inexpensive to implement, there is no true way to test its effectiveness until the procedure has taken place. Therefore, we can only accurately determine how this procedure works on patients that have a similar concentration of the C-reactive protein as our patients. So, when considering the availability and delivery of this product, we realized that it is not as easily marketable as we first thought. Indeed, this procedure would still have a positive effect on several people, but would be only a small portion of the total amount of POTENTIAL IMPACT The decision to implement this procedure will impact several people, including the patients that receive the treatment and their families, the personnel in the neurological department at the UPMC, and the field of bioengineering itself. I am fully aware that my team must adhere to the ASPE and BMES codes of ethics, and that we must also consider all the ramifications associated with these codes and the codes of neuroethics. One of the most crucial canons of both the ASPE and BMES ethical code is that “Engineers shall at all times strive to serve the public interest” [2] [4]. Within the context of my ethical dilemma, this is a crucial canon to consider. First, we must acknowledge that the public interest includes all of the people previously mentioned, and that each of these groups of people influence the total positive or negative impact of this procedure. Impact on Patients and Families The procedure will most directly impact the patients and their families. If the procedure is unsuccessful in depleting the C-reactive proteins, the patient will have no improvement in their emotional health and their families may lose hope in our hospital, and in this procedure. In addition, since we have been working specifically with Jane and John, then if we fail, they may lose hope in any other procedure. This procedure is specifically geared toward them and therefore it is of extreme importance that it is successful. We must also consider what the consequences are if the procedure is successful. If the procedure helps decrease the symptoms associated with depression and improves their mental health, then this is a positive result. However, there may be other significant changes within their mental state that would require an adjustment. Often, when altering or engineering any part of the brain, people think that a procedure may have an effect on the individual’s personality, which could cause emotional pain and a difficult adjustment for their friends and family as well as the individual. I have strongly considered and debated this, through my knowledge of psychology, neuroscience, and the consultation of outside sources. I learned that there is not one single cognitive 2 Christine Heisler the biomedical engineering profession” [4]. In accordance with these factors, I must make my decision on this case. So, I plan to also consult a code of neuroethics and a variety of other sources that have value to me personally so I can make the most informed and unbiased decision as possible. function that directly affects personality and behavior; it is a combination of several complex and intertwined cognitive functions. Therefore, it is not completely correct to assume that the alteration of one part of the brain will definitely change an individual’s sense of self. As stated in the article “Ethical Issues in Neuroscience”, even though there is a close relation between neurological state of an individual and personality, there is not a “definitive neural basis of morality or consciousness”, because this is such a complex aspect of a person [5]. I believe that our personality and sense of self is malleable, because the way we interpret who we are and what we feel changes quite often. Also, I believe that this procedure may have an effect on the neurological function of the individuals treated, but it will not drastically alter their personality or sense of self. I analyzed this issue further by reading alternative sources on the subject. An article on Quartz discusses the link between neuroscience and the sense of self. It discuss that the view of the self is ever-changing, not constant, as was previously believed. The article quotes from a neuroscience paper published in “Trends and Cognitive Sciences”. This paper states that “self-processing in the brain is not instantiated in a particular region or network, but rather extends to a broad range of fluctuating neural processes that do not appear to be self-specific” [6]. This further proves that personality and sense of self is determined by more than one area of the brain, by several complex processes. My team and I acknowledge that there have been several instances where different procedures have altered the personality of the patient, and we know that this is always a risk associated with surgical procedures on the frontal lobe of the brain, but we are confident that our procedure will be carefully performed and will have little to no impact on their sense of self or identity. CONSULTING NEUROETHICS The NSPE code of ethics and BMES code of ethics are helpful to reference when discussing any engineering issue. The NSPE code would be especially relevant in cases such as Case 1042, an example case I examined in my research process, because it explores the relationship between the workers and bosses and how information should be reported [7]. In my specific scenario, however, this case is not as applicable, so it is necessary to consider aspects of neuroethics as well. In Fuchs’ research article “Ethical Issues in Neuroscience”, these aspects are thoroughly examined. To start, Fuchs points out several cases where healthy individuals have used neurological drugs to enhance their cognitive function. [8]. Drugs targeted for patients with Alzheimer’s disease have been used to enhance the memory of healthy individuals, and drugs targeted for patients with PTSD are accessible to anyone who wishes to forget any remotely unpleasant event [8].These cases provide proof that any medication or procedure has the ability to be severely abused, and this leads to a substantial concern that our procedure could be misused by the general population. We could not feasibly account for every action of outside consumers, but if we applied our procedure in a clinical setting and to only a defined set of patients, then we could control its use. Once these initial procedures occur, we would take many precautionary measures to assure that this procedure would only be available to patients with diagnosed depression. Since it is such a specific surgical procedure, it is less likely to be as easily accessed and misused as an over-the-counter medication, but to protect against potential problems, we would need to take all necessary precautionary measures. Fuchs’ article then addresses another controversial topic; the topic of changing the human condition. He states that “mind enhancement threatens to devalue human life in all its imperfection.” [8]. I have considered this fact as well, and often questioned how I can morally attempt to change the human condition. It is certainly a question that all bioengineers must consider. If humans take a medication or undergo a procedure to become ‘perfect’ in any way, then how can we continue to call ourselves human? At what point does enhancement cross a line, and who has the jurisdiction to define this? These are questions that I will still be asking myself for years to come, because they require an amount of research and contemplation far beyond this essay. However, I can make a few observations about this at the present time. First, if any substance or product is used for a different purpose than it was intended, or if it is abused in an extreme case, then it has the potential to negate everything that human Impact on UPMC and Field of Bioengineering The result of the enzyme injection procedure will also impact my other team members and the entire neurological department of UPMC at the University of Pittsburgh. My team and I have spent a great deal of time developing a procedure that could treat depression, through our past research, education, and current work. Therefore, we would all be understandably upset if this procedure failed. Further, each individual in the department serves as a representative of the entire department in each aspect of our work, so if our team fails, it is also a failure for our department. Several law suits could arise as a result of our procedure and this would be a large detriment to the progress of our department, or any department in the UPMC, so we must make this decision carefully. Moreover, our decision on the implementation of this procedure will impact the entire field of bioengineering. Each bioengineer represents the profession as a whole, so we must hold each other accountable. As the BMES code of ethics states, bioengineers must “strive by action, example, and influence to increase the competence, prestige, and honor of 3 Christine Heisler beings are. In a similar way, if the procedure that my team and I have developed is used to augment human happiness and cognition in individuals who do not have any diagnosable need for this procedure, then this intervention is not only unnecessary, but extremely dangerous. But if this procedure allows an individual who has been living with depression to regain a relatively pain-free mental process and allows them to perform daily tasks to their full potential, then I absolutely support the implementation of it. I believe that an improvement in a patient’s current condition is definitely worth supporting, especially if it provides relief from the terrible grip of depression. This procedure would not dehumanize the patient in any way; they would still be the same person after the procedure, but now with the ability to live a more mentally stable life. Another issue that Fuchs addresses is free will, and this part of the article provides some insight into my overarching question: should we engineer the brain, and can people be held responsible for actions they take when their brain has been engineered? [1]. Several people, both in the medical field and in the general population, have the predetermined notion that a surgical procedure such as ours could not only affect personality but also have an effect on the free will of an individual. Fuchs addresses this and shows that free will is not solely determined by the finite neurological condition of the individual. It is “not concerned with neurons, muscles, or bodily movements that we act upon but with meaningful actions that we plan and intend in the context of our goals” [8]. Therefore, engineering the brain does not entail completely altering an individual, and this means that individuals can be held responsible even if a part of their brain has been engineered. I believe that, for the most part, procedures that are performed carefully and with minimally invasive techniques will not lead to a drastic change in the decision-making process of the individual. Therefore, they can still be held accountable for their own decisions. only be implemented within the realm of the clinical setting, and only administered to our patients and other patients with a similar C-reactive protein concentration. In this way, this procedure will help Jane, John, and other patients with a similar protein concentration, which was our original goal. Further, I believe that although the impact of this procedure may seem small in the context of the entire population that lives with depression, this would initiate progress that has much value in the development of a more effective treatment of this detrimental disease. Eventually, the procedure and our further research has the potential to eventually help a variety of patients living with depression, and this would be absolutely incredible. This ethical dilemma posed several questions. Although I may not be able to fully answer each question, I used a variety of information to make an initial decision: I searched for new information on the topic, relied on information I have already learned, and tried to analyze the dilemma from every angle possible. I reached this decision after carefully reading through each source and reflecting on it; so, for future engineers who face a similar dilemma, I would advise them to conduct their own careful analysis and to determine the steps of action accordingly. REFERENCES [1] Brey, P. ‘Biomedical Engineering Ethics.’ (2009). A Companion to Philosophy of Technology. Blackwell. [2] (2014). “Code of Ethics for Engineers.” National Society of Professional Engineers. (website). http://www.nspe.org/resources/ethics/code-ethics [3] Beckford, G.H. (2013). "Neuroimaging and Violence in the Education Setting." Online Ethics. Web. http://www.onlineethics.org/Resources/Cases/27564.aspx. [4] (2004). “Biomedical Engineering Society Code of Ethics.” Biomedical Engineering Society. (website). http://bmes.org/files/2004%20Approved%20%20Code%20o f%20Ethics(2).pdf [5] J. Illes, S. J. Bird. (2006). “Neuroethics: a modern context for ethics in neuroscience”, Trends in Neurosciences, Volume 29, Issue 9, September 2006, Pages 511-517, ISSN 01662236, http://dx.doi.org/10.1016/j.tins.2006.07.002. [6] Goldhill, O. (2015). "Neuroscience Backs up the Buddhist Belief that "the Self" Isn't Constant but Everchanging." Quartz. http://qz.com/506229/neurosciencebacks-up-the-buddhist-belief-that-the-self-isnt-constant-butever-changing/. [7] (2014). "Case 1042-Roman Holiday”. Ethics Cases. Texas Tech University: http://www.depts.ttu.edu/murdoughcenter/products/cases.ph p. [8] Fuchs, Thomas. (2006). “Ethical Issues in Neuroscience.” Springer, 2014. Web. [9] Orwell, George. 1984. New York: Signet, 1977. Print. CONCLUSION AND RECOMMENDATION FOR FUTURE ENGINEERS As Orwell states in his novel “1984”, “Nothing [is] your own except the few cubic centimeters inside your skull” [9]. When I read this brilliant novel in high school, I realized how precious the inner workings of our brain are, and how changes in these features can be severely detrimental. This novel is extremely poignant and applicable in several situations. Among other lessons, it taught me that protecting the intrinsic part of ourselves is vital, and throughout all of my research, I have kept this in mind. Through the consideration and analysis of different codes of ethics, several other sources, and this brilliant novel, I have been able to come to a conclusion about my ethical dilemma. I believe that our procedure should be implemented, with the following restrictions: it should 4 Christine Heisler ADDITIONAL SOURCES McGrath CL, Kelley ME, Holtzheimer PE, III, et al. Toward a Neuroimaging Treatment Selection Biomarker for Major Depressive Disorder. JAMA Psychiatry. 2013;70(8):821-829. doi:10.1001/jamapsychiatry.2013.143. ACKNOWLEDGEMENTS Many people were involved in the process of writing this essay. I would like to thank my writing instructor, Josh Zelesnick, for answering all of my questions about this assignment. I also want to thank my former classmate, Alex Cipriano, for taking the time to read my paper. She helped bring life to my paper and brought an outside view that I greatly needed. I would also like to thank my roommate who dealt with my stressful rants about this paper all week, and who took time to read parts of my paper. My paper greatly benefitted from all of their perspectives, and I am very grateful for their help. 5 Christine Heisler 6