Attention Deficit Hyperactivity Disorder: Defining A Spectrum Disorder and Considering Neuroethical Implications
James M. Swanson, Timothy Wigal, Kimberley Lakes, and Nora D. Volkow
Prospective follow-up studies have shown that even though some children outgrow the disorder, a childhood diagnosis of attention deficit hyperactivity disorder (ADHD) is clearly a risk factor for a broad range of adverse outcomes, with extremes including drug abuse and juvenile delinquency. This article considers the use of several spectrum concepts and some neuroethical issues. It provides a list of criterion symptoms with a threshold set for the number of symptoms required for categorical diagnoses of disorders. It gives a brief review of some brain imaging and pharmacological treatment studies of ADHD to set the stage for a consideration of brain-specific issues related to neuroethics. Studies using reaction time (RT) tasks of cognitive control, response inhibition, and conflict have identified interindividual variance in task performance as one of the most prominent aspects of cognitive deficits related to ADHD.
Lynn C. Robertson
Balint’s syndrome is the most severe neuropsychological disorder affecting spatial attention that has been observed. In humans, it can be observed after bilateral occipital-parietal damage. The signs and symptoms of this syndrome are first described and then discussed in terms of how research with patients with Balint’s syndrome has helped and/or limited our understanding of object-based attention, visual search, and feature binding in visual perception. The findings have also supported the existence of implicit spatial maps that are available in the face of severely limited conscious spatial awareness. The results of such studies have led to advancements in attentional theory, especially as related to spatial attention and its interaction with object perception.
New brain imaging technology has emerged that might make it possible to read a person's thoughts directly from their brain activity. This novel approach is referred to as “brain reading” or the “decoding of mental states.” This article provides a general outline of the field and discusses its limitations, potential applications, and also certain ethical issues that brain reading raises. The measurement of brain activity and brain structure has made considerable progress in recent decades. The mapping from brain activity patterns to thoughts is learned for each specific subject using brute force statistical pattern recognition techniques. It discusses the degree to which polygraphy and brain-based lie detection can be manipulated by trained subjects. A future application of brain reading technology, “neuromarketing,” has received tremendous interest and there are repeated attempts to optimize marketing campaigns by adding brain-based sources of information.
Jonathan D. Moreno
Bioethics literature on national security issues is surprisingly sparse and the implications of neuroscience for national security are of increasing public and scholarly interest. This article elaborates one important source of evidence that can be found in reports by US government advisory committees over the past few years. It demonstrates that the growing interest in neuroscience on the part of national security agencies can be discerned in part by reviewing recent reports from the US National Academies. The relationship between national security concerns and neuroscience is complex. Primary questions are discussed in the anthropomorphic terms of concerns and goals, and there is no inference to any particular sort of deliberations within these systems that leads ineluctably to a certain science policy agenda. This article also assesses the cultural underpinnings of neuroscience and ethical implications of evolving neurotechnologic capacity.
Chemical Cognitive Enhancement: Is it Unfair, Unjust, Discriminatory, or Cheating for Healthy Adults to Use Smart Drugs?
This article states that drugs could be used to produce, if not more intelligent individuals, at least individuals with better cognitive functioning. Cognitive functioning is something that we might strive to produce through education, including of course the more general health education of the community. Enhancements are good if and only if they make people better at doing some of the things they want to do including experiencing the world through all of the senses, assimilating and processing what is experienced, remembering and understanding things better, becoming more competent, and experiencing more. Beneficial neural changes have been reported for such familiar technologies as reading, education, physical exercise, and diet. Smart drugs create irresistible competitive pressures such that once they are used everyone is forced to follow in order to keep up, and this is coercive and corrosive.
Research is crucial to improve medicine's ability to care for the sick, and this includes research on conditions affecting cognition. This article focuses on whether persons suffering from diseases affecting cognition can be enrolled in research when the purpose is to investigate the condition leading to this impairment. It also discusses when they may be enrolled and on the precautions which are necessary if they are. Protections for vulnerable persons in research have two components: fair subject selection, and the specific care required to minimize wrongs to vulnerable persons once they are enrolled in research. Finally, the article examines, and rejects, the idea that there could be circumstances in which persons suffering from diseases affecting cognition could have an obligation to participate in research addressing these disorders.
Thomas Metzinger and Elisabeth Hildt
Cognitive enhancement aims at optimizing a specific class of information-processing functions: cognitive functions, physically realized by the human brain. This article deals with ethical issues in cognitive enhancement (CE). It discusses some standard conceptual issues related to the notion of “cognitive enhancement” and then continues from a purely descriptive point of view by briefly reviewing some empirical aspects and sketching the current situation. Several enhancement strategies are being tested and used. Then the chapter offers some reflections on the treatment or enhancement distinction. It turns to normative issues by describing standard topics in current debates, then highlighting three examples of relevant novel questions under an ethical perspective. It is of central importance to be able to draw on long-term studies yielding data on the benefits, risks, and side-effects involved in the use of such substances over months and years. It concludes by making some general proposals for policy makers.
Anders Sandberg, Walter Sinnott-Armstrong, and Julian Savulescu
Human cognitive performance has crucial significance for legal process, often creating the difference between fair and unfair imprisonment. Lawyers, judges, and jurors need to follow long and complex arguments. They need to understand technical language. Jurors need to remember what happens during a long trial. The demands imposed on jurors in particular are sizeable and the cognitive challenges are discussed in this chapter. Jurors are often subjected to both tremendous decision complexity and tremendous evidence complexity. Some of these problems could be ameliorated if we can somehow enhance the cognitive capacities, including attention and memory, of various players in trials. There are multiple ways in which cognition can be improved either by external tools or by an increasing number of biomedical interventions that act directly on the brain. The article surveys a range of beneficial and detrimental effects that substances can have on cognition.
Debra J.H. Mathews, Peter V. Rabins, and Benjamin D. Greenberg
This article reviews some of the ethical issues raised by the emergence and use of deep brain stimulation (DBS) as a treatment for neuropsychiatric disorders. Issues include concerns about the capacity of persons with severe mental illness to give authentic informed consent, protecting vulnerable individuals from being exposed to unproven and potentially irreversible therapies, the use of DBS for psychiatric disorders in minors, the necessary organization of the interdisciplinary teams required to deliver these demanding treatments, and the degree and quality of oversight. DBS may be seen as the most recent on a continuum of surgical intervention for psychiatric disease and also represents an adaptation of the first implantable brain-interfacing device (IBID) in clinical use. Consideration of the ethical issues raised by such therapies will protect individuals with neurologic and psychiatric diseases from the abuses of the past.
Development of the Adolescent Brain: Neuroethical Implications for the Understanding of Executive Function and Social Cognition
Brain research has informed many recent studies of adolescent development either through direct measures of brain structure and activity in neuroimaging studies or through behavioral studies where laboratory tasks are selected on the basis of their links to brain function. This body of work has led to a popular understanding of adolescence as a time period when risk-taking behavior escalates to extreme levels due to brain-based immaturities. This article considers neurobehavioral studies that allow us to conclude about executive functions in adolescence, studies of brain development that indicate about the status of the adolescent brain, and then, importantly, if these research domains cohere. The article analyses that brain-based substrates clearly underlie the immaturities in executive function observed in adolescence. The practical and ethical implications of these findings are discussed using legal decisions as a prominent example.
Gaia Scerif and Rachel Wu
Tracing the development of attentional deficits and their cascading effects in genetically and functionally defined disorders allows an understanding of intertwined developing systems on three levels. At the cognitive level, attention influences perception, learning, and memory. Attention and other cognitive processes interact to produce cascading effects across developmental time. At a systems neuroscience level, developmental disorders can reveal the systems and mechanisms necessary to attain adults’ efficient attentional processes. At the level of cellular neuroscience and functional genomics, disorders of known genetic aetiology provide inroads into cellular pathways and protein networks leading to attentional deficits across development. This chapter draws from both genetically defined and functionally defined disorders to delineate the complexities and necessity of studying attentional deficits and their neural correlates. Studying developmental disorders highlights the need to study attentional processes and other cognitive processes (e.g. memory and learning) in tandem, given their inseparable nature.
Claire Sadler and Rebecka Peebles
Children and adolescents with eating disorders are likely to present with or develop medical complications that require early intervention and treatment. This chapter discusses the most common medical sequelae within each organ system, while focusing on pertinent developmental differences between adult and pediatric populations. Although complications of anorexia nervosa have been relatively well documented, children and adolescents with other eating disorder diagnoses also experience complications and should not be discounted. Complications may include poor cardiac health, bone loss, changes to the endocrine system, loss of menstrual and gonadal function, loss of brain mass, electrolyte imbalances, and vitamin deficiencies. These medical issues may become severe enough as to cause death, and should be taken seriously and treated with urgency. Medical complications are often reversible if addressed quickly and properly. Criteria for hospitalization are also reviewed. Further studies of the medical complications of eating disorders in males, adolescents with chronic illnesses, and in those who have a history of being overweight or have had bariatric surgery are needed.
The Developmental Psychopathology Perspective on Externalizing Behavior Dimensions and Externalizing Disorders
Stephen P. Hinshaw and Theodore P. Beauchaine
This chapter highlights key principles of developmental psychopathology (DP), the discipline that eschews static models, universal and unbending laws of development, and inflexible categorical diagnoses in favor of transactional pathways and integration of multiple levels of analysis to achieve maximal understanding of psychopathology. The chapter emphasizes the mutually informative nature of investigating normal and atypical development; importance of considering developmental continuities and discontinuities; inclusion of analysis levels spanning the spectrum from genes to community-level influences on atypical development; transactional models of influence, which subsume important constructs of equfinality and multifinality; and risk and protective factors and processes. The key conclusion is that unless DP principles, concepts, and models are incorporated explicitly into investigations of externalizing behavior, the field is likely to misunderstand the highly dynamic and developmental nature of externalizing disorders and thereby miss key opportunities for deep understanding, evidence-based prevention and treatment efforts, and stigma reduction.
Neuroscience opens new avenues to alleviate neurological and psychiatric disorders and presents targeted ways to control and enhance vegetative (being awake or asleep, and appetite and sexuality) as well as mood and cognitive behaviors (memory to ideation). It considers a general trend to obtain improved memory and comprehension capacities through “smart pills,” rewards from technical progress. The article shows that currently available drugs will not only change some quantitative aspects of neural activities, whose improvement implies no problem, but also the global internal economy of cognition. Cognitive enhancers do not only change the amplitude of a given brain capacity, i.e. memory, but also the balance between emotional and rational networks. This article argues that the real risk resides in a hypertrophy of the self, losing essential feedback from the eyes of the others. These fundamental changes provide an understanding of the driving forces of “neurotechnological gourmandize”.
Ging-Yuek Robin Hsiung
This article explores some of the issues that arise in the post-human genome era and uses various cases to illustrate some of the scenarios that a clinician may encounter in decision-making. The overarching goal is to improve awareness and encourage discussion among the scientific and social academics, clinicians, patients, and stakeholders, as well as society at large. Neurological conditions for which genetic testing is currently available are listed. This novel technology has also introduced a burden of ethical dilemmas for clinical neuroscience. Genetic tests can be used in healthcare to detect gene variants associated with a specific diseases or conditions, and in non-clinical applications such for forensics, paternity testing and anthropological research. It discusses some situations in which clinical genetic testing is generally utilized. The most common scenario in which a genetic test is ordered is for confirmation of a diagnosis. Genetic risk factor analysis is expected to play an increasingly important role in healthcare for many common disorders, including many in the neurological realm.
Zachary Stein, Bruno Della Chiesa, Christina Hinton, and Kurt W. Fischer
A growing international movement, called educational neuroscience, aims to inform educational research, policy, and practice with neuroscience and cognitive science research. The research brings a powerful capability to directly intervene in children's biological makeup, stirring ethical questions about the very nature of child rearing, and the role of education in this process. This study argues that designing children is ethically unacceptable and presents a few case studies to highlight important ethical issues. This article focuses on a central issue—the distinction between two general types of educational interventions informed by neuroscience, designing children versus raising children. These scenarios envision educational reforms that might follow in the wake of advances in understanding the biological bases of ethical behaviors. It hopes to provoke others to consider emerging ethical issues in mind, brain, and education, and to take preemptive action to protect children's right to participate in their own development.
Nir Lipsman and Mark Bernstein
This article discusses ethical questions in neurosurgery as falling into two categories, namely those surrounding what neurosurgeons are currently doing, i.e. their current practices, and those surrounding what neurosurgeons will, theoretically, be capable of doing in the future, i.e. their future practices. It reveals the current and emerging applications of functional neurosurgery as well as the future controversies that will stem from them. It focuses on psychosurgery, enhancement (cognitive and physical) and the brain–machine interface (BMI), in order to illustrate the pertinent ethical challenges and the role of the neurosurgeon in helping to address them. These three applications represent natural extensions of each other, as an exploration of the underlying mechanisms of psychopathology will ultimately provide insight into normal brain function. Concerns about the future of implantable technology, and the neurosurgeon's role in installing it, need to be addressed.
Silke Appel-Cresswell and A. Jon Stoessl
The illness causes patients to suffer from increasingly severe and widespread dysfunction of the central nervous system leading to disturbances of sleep, sense of smell, autonomic function, cognition, motivation, and mood, as well as decision making and personality. This article concerns the genetics of Parkinson's disease (PD), functional imaging including imaging of pre-symptomatic subjects, and treatment of Parkinsonian diseases including novel treatments, side effects, the placebo effect, potential biases in the evaluation and promotion of therapies, and access to resources as examples of the numerous and varied ethical challenges associated with this neurodegenerative disorder. There are several issues encountered in the management of patients with PD in which ethical considerations may be important.
Roger A. Barker and Alasdair Coles
Effective treatments of neurodegenerative disorders are increasing in importance, as the prevalence of these conditions increases with an aging population. The ethical issues around the different uses of neural tissue are essentially the same. This article focuses on the specific example of Parkinson's disease (PD) where clinical transplantation trials are most advanced. The ethical issues generated by the transplantation of the fetal material can be categorized as those relating to the patient and physician, the trial design, and tissue. The article demonstrates that the primary goal of clinical studies of fetal transplantation should be to consolidate the technical issues around patient selection, graft preparation, and surgical delivery. Each of these areas present major problems and in some ways the field, still early in development, is defining the issues as it moves forward. The solution for these issues involves a wider discussion with governmental agencies that regulate much of this work and the society that they serve and protect.
Craig Van Dyke
This article addresses the expansion of clinical trials to the developing world as part of the globalization process. Driven initially by the need to reduce costs and the potential to access subject populations, the pharmaceutical enterprise has greatly expanded the number of clinical trials in low- and middle-income countries. As the number and complexity of clinical trials has grown, the challenges have become more apparent. Challenges include: poorly trained personnel, insufficient medical infrastructure, inadequate institutional review boards, lack of monitoring, conflicts of interest, and many ethical issues, especially protecting the rights of vulnerable populations during the informed consent process. High-income countries can also play a critical role in helping the developing world build their clinical research capacity. Such efforts offer the very real prospect of improving healthcare in the developing world.