Distributive justice is chief ethical issue with neurotechnologies
Socioeconomic disparities are one ethical concern
Executive Summary
Distributive justice is a primary ethical issue involving neurotechnologies. Ethical concerns include:
- Who will have access to treatments or enhancements;
- Who should have access to a test to detect limited consciousness in patients who have been diagnosed as being in a persistent vegetative or minimally conscious state;
- How risks and benefits are distributed among beneficiaries of these technologies.
The most pressing ethical concerns about neurotechnologies involve distributive justice, according to Thomas Cochrane, MD, MBA, senior ethics consultant at Brigham and Women's Center for Bioethics and assistant professor of neurology at Harvard Medical School in Boston.
"Who gets to benefit from these technologies, and how do we pay for them?" Cochrane asks. "If only wealthy people have access to treatments or enhancements, this could aggravate pre-existing socioeconomic disparities." Here are some ethical concerns involved with various applications of neurotechnologies:
• How should you utilize a test that can detect some consciousness in a patient who looks unconscious?
This is an issue because researchers have used functional MRI techniques to detect limited consciousness in patients who had been diagnosed as being in a persistent vegetative state and a minimally conscious state.1
"If we knew that detecting consciousness in such a patient was predictive of improvement, then naturally it would impact the decision to continue life support or not," says Cochrane. The techniques are labor-intensive, and are only available at specialized centers; even then, they are largely only available as part of a research protocol.
These technologies aren't necessarily available when providers go to the bedside, says Marleen Eijkholt, PhD, LLM, a clinical ethics fellow at Alden March Bioethics Institute at Albany (NY) Medical College.
"The technologies may not provide concrete, practical input around end-of-life decisions," she says. "Or they may be just too expensive in light of uncertain practical benefits."
• Who should have access to cognitive enhancers?
Ethical questions arise as to how individuals use pharmacological drugs normally prescribed for treatment purposes, such as methylphenidate or modafinil, to enhance cognition, says Eijkholt. For example, healthy students could use such drugs to enhance their concentration during school exams.
"We are talking about issues of fairness," she says. "If healthy people are using them, is it fair that they are so expensive that only the elite can profit from them? Should they be available for 'healthy' individuals at all?"
Clinicians and researchers have knowledge about the safety and efficacy of cognitive enhancers, says Eijkholt, but bioethicists can bring light to concerns about distributive justice.
Bioethicists could point out, for example, that increasing numbers of pharmaceutical enhancers are being tested; besides safety concerns, there are also concerns about societal risks and benefits.
Bioethicists can also help contribute to the discussion about how to make a distinction between what constitutes therapy and what constitutes enhancement.
"Therapeutic interventions and drugs are often justified stating medical reasons; their costs or availability are hardly questioned," says Eijkholt. "Enhancers lack this justification, and, therefore, raise issues about distributive justice."
• How should neurotechnologies be applied to identify neuropathways of addicted individuals?
This application raises another set of ethical concerns, says Eijkholt. "We need to think further than the most obvious distribution issues and issues of fairness," she says. Some risks are not as clearly visible, such as stigma.
"I see a role for bioethicists to go outside their academic field and reach out into the public domain," says Eijkholt. "We need to make the debate accessible, and not too 'highbrow.'"
Reference
- Owen AM, Coleman MR, Boly M, et al. Detecting awareness in the vegetative state. Science 2006;313(5792):1402.
SOURCES
- Thomas Cochrane, MD, MBA, Senior Ethics Consultant, Brigham and Women's Center for Bioethics/Assistant Professor of Neurology, Harvard Medical School, Boston, MA. E-mail: [email protected].
- Marleen Eijkholt, PhD, LLM, Clinical Ethics Fellow, Alden March Bioethics Institute at Albany (NY) Medical College. Phone: (518) 262-1531. E-mail: [email protected].
