Neurotechnology, Evidence, and Ethics
On the “Groundswell” of Neurotechnology
Recently, a reader wrote to comment on my essays regarding neurotechnology in light of the growing number of advertisements for various neurotechnologically-based devices seen in this, and other, pain journals. Writing, “…there’s been practically a groundswell [of information and advertisement]…that often is confusing, seems contradicting and, in some cases, it’s obvious that real evidence isn’t available…how can physicians and the general public, for that matter, know what’s ‘snake oil’ and what’s legitimate, and if these devices are safe, and how they ought to be used?” this reader’s thoughtful comment takes note of an increasing presence of neurotechnology in pain care, if not medicine and other dimensions of public life in general.
The medical use of machines is certainly not new, and a brief history of medicine since the second industrial revolution will reveal the steady infiltration of various devices into the clinical milieu.1 This has tended to reflect the iterative technologization of much of western society. As previously noted, the aims of such technologization—namely to ease the human condition and to incur time- and cost-efficiency—married well to the expansion of medicine as a profession and practice in the early 20th century.
These incentives also wedded technology and its use(s) to a broadening influence of the market, and this fusion was mirrored—even if somewhat in caricature—by the profligate claims of “wonder devices” that could “cure” a host of disorders including, if not most typically, pain.2 To be sure, many such claims were sheer quackery, and the Flexnerian reformation of American medicine certainly lessened the frequency and abundance of these transgressions.3 Yet, every new technologic turn is accompanied by speculation, expectation, hopes and fears, and the outgrowth of neurotechnology following the Decade of the Brain (DoB, 1990-2000) certainly reflects this process. The astute comment provided by the reader speaks to the apparent “pop-up” of neurotechnologies germane to the diag-nosis and treatment of pain, attributable at least in part, to the carry-over effect of technologies developed during the DoB being focused upon practical applications during the Decade of Pain Control and Research (DPCR, 2000-2010).4 Economic subsidies for research directions and biotechnological applications certainly contributed to this pattern and have also created a market niche for such neurotechnology. How (i.e., in what ways, to what ends) this niche will be filled may be contingent upon the environment fostered by the Decade of the Mind (DoM) project, its affiliated Neuroscience, Ethics, Legal and Social Issues (NELSI) agenda, and the work of the National Neurotechnology Initiative (NNTI) and Neurotechnology Industries Organization (NIO).5
“‘…how can physicians and the general public, for that matter, know what’s ‘snake oil’ and what’s legitimate, and if these devices are safe, and how they ought to be used?’”
Recently, Michael Schatman and I have written that pain medicine currently faces a “crisis”—a time of change upon which rests potential future trajectories for the scope and breadth of care.6 Without doubt, neurotechnology, both alone and in concert with other (e.g., geno-, nano-, and cyber-) technological advances have contributed to, and will factor into these changes and the socio-medical milieu that results. But as we’ve noted, neither change itself, nor the nature of what emerges status-post-change are passive events, and pro-active investment of time and effort are required to assure that change is as positive as possible. A part of the crisis we’ve described rests upon ethical issues, questions and problems that arise in, and from the ways that we approach, address and utilize new scientific and biotechnological developments in research and practice.7 As our reader’s commentary has implied, this “ground-swell” of new development is evident, and the aforementioned ethical questions cannot be ignored. In this essay, I explicitly address the point that some neuro-technologies have not been thoroughly studied, have been (and are being) used in ways that are based upon dubious claims regarding mechanism(s) or outcomes, are being used by improperly and/or untrained providers, and/or are simply being used in ways that are inapt. I will also discuss the ethical obligations that undergird the use of new neurotechnologies in pain research, assessment, diagnosis and treatment.
I have previously argued that pain care, like medicine writ large, is not simply applied science, but rather uses scientific tools and technologies and the information they afford in ways that uphold the fiduciary both between clinician and patient, and medicine and society.8 This reflects the reciprocity of science, technology, research and clinical practice as a true “practice” (i.e., an exchange of good between agents in community, as defined by the nature of their relationship9). It is in this light that the imperative to elucidate the mechanism, capacities, limitations, and evaluate the outcomes of any and all neurotechnologies that are used in clinical diagnosis and therapeutics for pain (as well as any other clinical application) becomes important.
“...we continue to confront the fundamental “hard problem” of not understanding how consciousness and related mental processes actually occur, so any and all concepts that relate the effect(s) of a technology to a mechanism of mind remain tentative.”10,11
While neuroscience provides considerable insight to the structure and function(s) of the brain, we continue to confront the fundamental “hard problem” of not understanding how consciousness and related mental processes actually occur, so any and all concepts that relate the effect(s) of a technology to a mechanism of mind remain tentative.10,11 Moreover, every brain is different with regards to the network dynamics that subserve cognitions, emotions and behaviors.12 Therefore, it becomes evident that employing neurotechnology in a “one-size-fits-all” approach to modifying brain-mind function is both technically and ethically inappropriate. Given the individual uniqueness of the brain-mind, it is vital to weigh the effect of neuropsychiatric predispositions, co-morbidities, etc, when evaluating the relative ratio of benefit, burdens and risks that the use (or non-use) of these technologies might incur.13 Moreover, we simply do not know how the use of these technologies might alter the long-term function or structure of the brain. This is where the “mechanistic dilemma” comes to light.14 In “western” medicine, a technique or technology may not be “accepted” unless or until its mechanism is ascertained.15 On one hand, this might tend to militate against the use of such technology (even if positive outcomes are, in fact, available). Yet, despite what would appear to be a negative bias, a mechanistic understanding is valuable, if not essential, to assess the potential for adverse effects.