Posted on August 18, 2011 at 9:21 AM
Recently, Adrian Carter discussed the move toward adopting a disease model of addiction. A disease model can be useful in that it often substantiates and compels search(es) for prevention, cure, or at least some form of effective management. Of course, it’s presumed that any such treatments would be developed and rendered in accordance with the underlying moral imperative of medical care to act in patients’ best interests. But this fosters the need for a more finely-grained assessment of exactly what obtains and entails the “good” of medical care given the variety of levels and domains that reflect and involve patients’ values, goals, burdens, risks and harms.
As Carter notes, neuroscience offers knowledge and tools, but like any insight or capability, these can be improperly used, and/or frankly (and perhaps intentionally) misused to achieve ends that are inconsistent with the moral obligations of medicine.
Rigorous studies of the neural basis of addiction – and its potential treatments – are important to both define the biology of such conditions, and also to more accurately depict how neural mechanisms of cognition, emotion and behavior are influenced by – and affect – the psychosocial aspects of the patient, and the culture in which patients are nested. I believe that there’s a particular imperative to further and better describe and define the neurobiological and psycho-social substrates that are operative in drug-, gambling- and even internet-use and overuse, given that these behaviors are to be classified as “addiction” in the forthcoming DSM-5 (that is now in field trials). The intent of this more broadly construed categorization is to explicate these conditions as pathological, and in this way, align their diagnosis and care with the medical model (and in so doing effect good for those persons who are so afflicted).
But let’s not forget that patients – and medicine – exist in a social environment that is governed by law(s), and the language of society at-large, medicine, and law often differ in terms and intent. Even when terms cross these domains, their meanings and utility can and frequently do differ (think, for example of words like “insanity,” “conscious/consciousness,” “competent,” “capable,” and in extremis, even the meaning of, and criteria for, “dead.” Thus, the wedding of a bio-medical model and a legally-pregnant term opens a virtual Pandora’s Box of potential problems.
Neurobiology is important to any naturalistic construct of the human being, human behavior and human condition, and should be part of the calculus when assessing and trying to determine causality, capability and, as David Eagleman has often argued, even culpability. But while a vital variable, it is not the only variable. We’ve moved beyond the proverbial nature vs. nurture debate and settled into a more complementary – and realistic -perspective that Matt Ridley refers to as “nature via nurture.” This reflects George Engel’s notion of humans a bio-psychosocial organisms, which nicely sets up the fact that there’s an ongoing and reciprocal interaction of human biology, psychology (as individual and group cognition), and social environments and circumstances.
While this can generate a pretty extensive discussion of the whys, whats, and hows of these interactions, I’ll leave that for another time and focus on what I feel is a very pragmatic issue. Namely, that neurobiologic and psychologic aspects of human health, activity and disease are expressed in the social sphere. So, if we assert that certain neural mechanisms that influence reinforcement-seeking behaviors are considered to be pathologic, call that condition “addiction”, and categorize it as a medical disorder, then we should be prepared to appropriately change the psycho-social construct of addiction to match, in order to de-stigmatize the disorder, align legal approaches to the term, condition and those who are affected by it (viz. “addicts”), and empower the use of medical resources and services to treat it. Things can get sticky – if not downright criminal – for patients, clinicians and society when “fuzzy definitions” of medical conditions and their treatments incur legal ramifications.
But the fact that neuroscience (as a tool), medicine, and law exist in, and as functional dimensions of society also suggests that society – or more realistically the people who comprise society – makes certain requests and demands of science, healthcare and the justice system. It’s the call for social good that sustains the use of neuroscience in biomedicine, and defining such good for the individuals and groups that make up society is important to guide how neuroscientific research is conducted, and in what ways and to what ends its techniques and technologies are applied.
We as a society (writ-small as a society of professionals, and writ-large as a worldwide collection of communities) define what standards shall be employed to make claims of normality, abnormality, order, disorder, conformity and deviance. And while it is fine to think that the call for neuroscientific diagnoses and treatments of “addiction” are solely based upon the beneficent motives of medicine, let’s stop a minute and ask if such directives for intervention would be so pressing if the ramifications of what we construe as “addictive” behaviors were not socially castigated or outside the letter of the law.
This reflects a broader issue. Often, society calls for science to respond to the ills of the human condition, and prevent or fix certain aspects of the human predicament of pain, sadness, suffering, violence and even death. We have looked to science to better explain why things happen to us, and in us, including the human propensity for pleasure, non-conformity and violence. We ask “what is it about our nature that fosters such thoughts and actions”, and how can we employ science to predict, prevent or reduce these aspects of our nature? Events such as the shootings in Norway, Phoenix, and Columbine, the violence and aberrance that confronts us in the daily news, all evoke a social plea for science to “do something.” Yet, we recoil when “doing something” entails the use of currently available techniques and technologies to define, predict, and/or mitigate such socially disruptive acts.
The sniff of Manchurian Candidate, Terminal Man, and Minority Report scenarios, coupled with very real – and legitimate – concerns about trumping individual autonomy, invasions of privacy, and scientific totalitarianism all tend to squelch the use of these neuroscientific approaches (and by this I mean “convergent” neuroscientific approaches, inclusive of genetics, imaging, cyber-linked data bases, pharmacology, and internal and external neurotechnological devices) in such ways. Adrian Carter is right when he states that “moral responses can shape the way that neuroscience research is understood and applied,” and that findings can easily – and readily – be “misunderstood and misused;” points that I’ve consistently emphasized as important, not only for the public conception of things “neuro,” but for biomedical utility and employment of neuroscience and neurotechnology, as well.
But Carter’s claim that neuroscientific research should not be used “…as a way of controlling deviant social behavior…achieving other social goals…such as reducing crime or criminal justice costs” might lean toward misconstruing what ought to be with what is (i.e.- the naturalistic fallacy). Let’s not be naïve, science – including neuroscience – is used to achieve particular social goals, whether they be healthcare, improving the quality of daily life, striving to flourish, or making and keeping the public “safe.” Science is a public good, and as such, can be leveraged in ways that affect the relative costs and values of other market factors (to which recent debates regarding the provision of high-tech healthcare will attest). Included among these is the need and call for reducing the economic impact and burden of disease, illness, and crime. To be sure, there are profound humanitarian aspects to such a call, and this cannot be denied. In fact, I pose that it’s the very balance of humanitarian and socio-economic considerations that are necessary to effect the ethically sound use of neuroscience and neurotechnology. One need only to look closely at the “public health” rhetoric of Hitler’s Germany to find evidence of what can happen when socio-economics – absent humanitarian regard – are used to play upon and leverage public opinion about the ways science can be used to incur heinous ends.
Let’s not throw out the baby with the bathwater. Neuroscience is a powerful tool, and its power can be rendered whether the knowledge and capability it provides are used correctly or incorrectly, or in ways that produce good or harm. But neuroscience is not an independent entity; it is a human enterprise, and is used by humans for humans (including ways that influence their insight, relationship, regard and treatment of non-human species). We as individuals, communities and societies decide what to study, what results mean, how much information is sufficient to generate certain uses and actions, and what actions and applications should be taken with the tools and knowledge at hand. It’s crucial that we recognize the power of this capacity, and strive to wash the dirt of mis-appropriated science and its outcomes down the drain, while keeping the need for, and importance of rigorous science, its outcomes, and potential for it to provide ethically solid, beneficial social effects intact and squeaky clean.
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