THE ETHICAL PROBLEMS OF BRAIN MANIPULATION
Psychosurgery and electrical stimulation of the brain are among the most dramatic of new technologies for controlling human behavior. To explore the social and moral implications of such...
...DELGADO: It's both ethical and technical...
...It is altogether plausible that doing so in an intelligent, careful SPECIAL FEATURE way will permit you to directly ameliorate his behavior...
...PAUL WEISS, Heller Professor of Philosophy at Catholic University of America, whose book Man's Freedom deals with the scientific control of man...
...380 The more usual pattern of violence seen at the Boston Veterans Hospital indicates that trivial events would precipitate these rages...
...The man goes crazy...
...What I would find helpful—since I think it is impossible to have a general formula or some sort of a deductive way for deriving a justification for a procedure—would be to get from you people [the scientists] hints as to where you're suspicious of your own reasoning, where you've gone wrong or have suspected your own motives...
...On the other hand, this technology by itself doesn't do anything...
...MARK: This is a man sensitive to every little change in his environment...
...We try to repair this terribly damaged human brain and see if we can make it operate better...
...The brain, I think, should be conceived as a special environment for the person...
...Vaughan then pointed out that the social-environment issue makes it virtually impossible to do an adequate evaluation of treatments...
...First, who is to give consent...
...PRIBRAM: This means that epilepsy as such is irrelevant in this case...
...What has disturbed me most in this whole meeting is that you've asked Dr...
...What procedures should there be for responding to the value horizon, and where is present research headquestion— regarding codes, legislative deci ing...
...we do not invent these building blocks, they are given from the outside and they change the structure of our brain...
...Dr...
...th the raising of the political dimension of the consent procedure, the floor was turned over to Dr...
...With all the management they've tried, they feel he is much too dangerous despite all the medication they've given him...
...She was put on L–Dopa and within 48 hours the symptoms disappeared completely...
...Now fortunately this is very directly related to the extensiveness of the scar...
...DELGADO: You're absolutely right...
...LONDON: If I understand correctly, Dr...
...Is it possible to explain brain surgery where the outcome is so equivocal...
...Mark said the committee of three distinguished Harvard colleagues, professors of psychiatry and neurology and surgery, was to review this, and that they "had absolutely no connection with the program...
...PERRY LONDON, professor of psychology and psychiatry at the University of Southern California, whose book Behavior Control surveyed the entire field...
...But it seems to me that the techniques we're discussing now raise two important practical questions...
...It is hard enough to explain complicated abdominal surgery to a layman...
...About what generally accepted moral assessSecond, what techniques are on the near ments do you feel uneasy...
...The brain is a public object...
...Our discussion so far has often turned on whether or not there is a fixed nature to man, of what would be normal for man...
...There's one sentence that I think was erroneous in the case presentation—I'd like to repeat it, I think verbatim...
...Notwithstanding the expertise of the neurosurgeons, I don't know that we can enjoy the luxury of the neurosurgeon making the decision whether to operate much longer...
...What would you do...
...And in the brain we have mainly three types of controls: (1) mechanical, through surgery, (2) electrical, through brain stimu lation, and (3) chemical, by placing drugs inside the brain (I'm not talking about drugs taken by mouth, only direct application of chemicals in the brain) . Then, there is a fourth type of control, the effect of the en vironment on the electrical and chemical activity of the brain...
...BEECHER: I think Dr...
...I know I have a mind, but it's only a theory I have a brain...
...They cannot contain him in psychiatric hospitals—neither state hospitals in Minnesota nor in the veterans' hospitals of the federal system...
...Within another 48 hours the mother, who was the legal guardian and the only one permitted to give consent, asked that they stop the treatment...
...He isn't the same person any more...
...Secondrate people will do what Dr...
...Since the conference was held, concern about abuses in psychosurgery has grown, leading to demands that the procedures be more carefully limited, or even banned...
...Furthermore, there are different precedents in dif ferent jurisdictions...
...MICHELS: Let's say the general social attitude toward the procedure was positive and the patient, when disturbed and belligerent, wouldn't consent...
...It was obvious that if the girl was left on L–Dopa, it would be destructive to the mother who had built her entire life around looking after the patient...
...This caution applies to psychosurgery in the following way...
...Sweet...
...And, finally, the judicial process does not come to bear unless someone files a suit...
...ANN ORLOV, editor for the Behavioral Sciences, Harvard University Press and Fellow of the Institute of Society, Ethics and the Life Sciences...
...To explore the social and moral implications of such technologies, the Institute of Society, Ethics and the Life Sciences in Hastings-on-Hudson, N.Y., has established a behavior control research group, which, in December 1971, held the Conference on the Physical Manipulation of the Brain...
...LONDON: On the one hand, you're telling us about the immediate potential of the technology of brain implantation and about the philosophical implication—the practical philosophical implication—that we can define man as a constructible entity...
...THE ETHICAL PROBLEMS OF BRAIN MANIPULATION Citing the controversial practice of amygdalotomy on hyperactive children, he said that we simply do not know the effects of this operation on the children's future capacities for learning...
...She had had Parkinson's disease since she was 20, and she was brought into the hospital, together with her mother who was her legal guardian, because the Parkinson's was so severe that she was unable to take care of herself...
...but the problem has nothing to do with that...
...Can we assume that therapists, physicians, behavioral psychologists, and psychiatrists can make the choice as to the symptom or the behavioral change that is to be modified...
...In a sense it's an example of a procedure eliciting the consent for the procedure...
...NEVILLE: You're right in pointing out that the ultimate problem turns out to be not a medical but a political one...
...364 Now would you rather try ESB or decapitation...
...If he's not rational we hope that his closest relatives will be glad he had it...
...MICHELS: It seems to me that if you pose the problem this way, the rest of us kind of have to shut up while you tell us whether you think there is such a thing as a natural or platonic way of looking at the world or whether you want to adopt the notion that it's the court or some arbitrary device of society which defines its values...
...GAYLIN: I think he's asking a broader question, because I know Dr...
...SWEET: I would say that psychosurgery is seeking to move forward in a far more cautious and critical fashion than that which characterized the tremendous wave of enthusiasm for this tactic of making lesions in the human brain in psychosis and behavior disturbances back in the '40s and early '50s...
...Whenever the brain is injured in any way, there's a resultant healing process, and a seizure tendency develops in a significant number of people...
...they used for, and how well do they work...
...Education provides a frame of reference for each child...
...However, let's say that this can be circumvented...
...A surgeon operating on a person's brain has gone into the inside of his perimeter of defense, as it were, and the person can't cope with it very easily...
...government belong to the people—it is not said just what those rights are...
...On the other hand, what several people meant was, Who has the right to do what and who gives consent...
...Arguments are minute, careful, and judicious, and based upon evidence...
...It seems a court of nonphysicians would be a much more appropriate court to make the final decision...
...Furthermore, we are technically able to perform a much more precise and limited kind of destruction...
...The physician is always in the position of weighing the risks of what he's doing, the immediate risks and the long-range risks, with the possible therapeutic benefit—immediate therapeutic benefit, and the potential remote therapeutic benefit...
...we don't even ask the parents whether they want to educate them...
...CHALKLEY: The basic question, I hope, is essentially one that Dr...
...wEISS: Then you're in conflict, aren't you, with those who say that you haven't the right to suicide, and that procreativity is a condition determined by the number of people that can be sustained...
...we've always tried to do something about abnormal behavior...
...PRIBRAM: The right, yes...
...How do we know when enough is enough...
...There are all sorts of exceptions to this, of course...
...I do not believe that we must be slaves of natural chance...
...There seem to me three kinds of criteria against whatever alternatives there might be...
...What kind of experiments do we require of animals and what kind of leaps of faith must we then take after experimenting with animals before we dare apply the same techniques to human beings...
...I think Dr...
...Save a lot of money THE ETHICAL PROBLEMS OF BRAIN MANIPULATION by putting electrodes at $1,000 each, into the brains of children...
...I think that's the ethical issue...
...Delgado, I'm closer to being in sympathy with Dr...
...Rather, it is a closely in tegrated system in which certain systems have an extraordinary overlap and interdeSPECIAL FEATURE pendence of functioning...
...We go too far in believing this structure can be modified when we talk about changing the definition of man, asking ourselves what kind of man we would want to construct...
...But what about other side effects...
...To a psychiatrist at least, the fact that it could produce this much passion, this much vitriol, suggests that it seems substantively different...
...And that's terribly important because that means that Conference Guests Included: HENRY K. BEECHER, M.D., Henry Isaiah Dorr Professor of research in anaesthesia, emeritus, Harvard University, author of Research and the Individual: Human Studies, and Fellow of the Institute...
...Ordinarily, we think the scientists are in charge of the criteria and the patient or his family is in charge of the consent...
...Certainly we can't begin to detect, evaluate, or measure the limitation caused by the operation until we have some idea as to what is the limitation caused by the disease...
...On the one hand, what we mean by the problem of justification is finding the criteria for deciding when to do what...
...Pribram] implying an operational ethical principle to apply in evaluating techniques for physical manipulation of the brain...
...MARK: At the present time, we [in the Boston City Hospital/Massachusetts General Hospital neurosurgical-neurological group] are only considering for surgical intervention those people with focal brain disease and violent behavior who have temporal lobe epilepsy, who would be, in fact, candidates 378 SPECIAL FEATURE for surgical operation even if they didn't have violent behavior...
...How do you see this technology progressing in such a way that it orients us toward that longer-range goal, and what are the dangers that you see in connection with that...
...GAVIN: You can always find some hack...
...Is THE ETHICAL PROBLEMS OF BRAIN MANIPULATION 369 not a man more than what is available through public external determination...
...A neurological assess ment by the head of neurology at Boston University was summarized by citing the fact that he felt that this man was a temporal lobe epileptic even though he didn't have seizures...
...As scientists we don't think of the brain any more as a mosaic of centers and structures having to do with rather specific aspects of behavior and experience...
...SWEET: At that stage of the game I would assume that a good many of the present crit ics would be muted, if not silent, and I would reconsider the matter...
...So he went into his cell, put his hand through a brick wall and took out the toilet bowl, in toto, ripping it out of the wall and shredding it through the bars...
...EHRENSING: I'm defining freedom very broadly as self-determination...
...but then you turned off the electrodes and he again wouldn't consent...
...Neville voice the supposition that the brain is somehow "inner...
...Or the individual himself may recognize that he's about to be, or may well be, in that situation...
...What exactly should a reasonable person know to be in a position to give or withhold informed consent...
...Dr...
...Patient Arthur P., 29 years old and an exMarine, has been showing episodic violent behavior of a particularly threatening and destructive kind...
...Pribram proposed a new bill of rights to be appended to the present constitutional amendments...
...What are the limits of essential humanity...
...Anticipating an unfavorable reply from this committee at Mass...
...WILLIAM H. SWEET, M.D., professor of surgery at Harvard Medical School and chief of neurosurgery at Massachusetts General Hospital...
...ORLOV: Dr...
...That's within the range of possibility...
...Further discussion began with Dr...
...GAYLIN: The Institute has convened long-range developments...
...We are a conglomerate of cultural values, with the symbols determined by culture and experience...
...It made people easy to control and easy to handle but, God forbid, at what a cost...
...it is also a problem of communicating what we actually know of men as they are...
...ORLOV: Do you really believe that we should try to restructure society and reeducate man in this fashion...
...Ervin and Mark—they're the principals...
...What issues are peculiar to these techniques (or to these plus chemical therapy...
...Then a pneumoencephalogram was taken, which showed that he had a distinctly and definitely abnormal left temporal horn with a dilitation of the lateral cleft and an irregularity of the supra cornual cleft...
...Rasmussen, assuming that the technical problems were in fact solved and that you could with good consciences as doctors be satisfied with the results that you would get with your patients, are these techniques in Conference Participants from the Institute Research Group Included: DANIEL CALLAHAN, director of the Institute, moderated the Conference...
...Another form of public policy rests in the administrative and regulative bodies of the government, such as HEW and the Food and Drug Administration...
...The diminution in complexity, 374 really, seems to be dehumanizing and for that there must be a very, very impressive gain in order to make that an acceptable cost...
...think would' be desirable long-range research...
...Yet I'm still troubled by two assumptions I think Dr...
...Is this, then, a good reason for not seeking to learn how to control murderous behavior in those individuals who have de monstrable organic brain disease...
...this showed cascades of "spikes" from both temporal areas via sphenoidal leads...
...I notice the neurosurgeons are concerned with the blandness that's created by some procedures...
...By conceiving of the brain as an environment that inhibits or fosters these human activities, we can conceive the techniques relative to the freedom and values of the person...
...We would like to find, say, techniques for modifying criminal behavior that are most respectful of the criminals, so long as they're efficient and the social costs are not too great...
...JAMES R. GAVIN, III, a biochemist at the National Institutes of Health interested in the social aspects of science...
...This is not always the correct approach...
...EHRENSING: Somewhat...
...psychosurgery and electrical brain stimula-In all these topics, we are interested not so tion...
...RUDOLPH EHRENSING, M.D., assistant professor of psychiatry, Louisiana State University Medical Center, interested in the behavior problems of adolescents...
...When the mother was in the room she agreed with the mother and said that she did not want to be treated...
...The second is the right to territory...
...The word aggression and violence is really a very broad term...
...GAYLIN: Right...
...At the present time they are trying to recommit him for life to the St...
...He would often be very distressed at his own behavior...
...Modifying the brain, since it's the most initimate environment for our humanly prized emotions and thoughts, is likely to THE ETHICAL PROBLEMS OF BRAIN MANIPULATION 371 have more pervasive effects than modifying certain other kinds of environment...
...The third is the right to integrity, meaning a reasonable guarantee of individuality and personal identity...
...Mark...
...However, the information obtained about learning, memory, emotionality, etc...
...This also is new...
...And that, as Dr...
...Delgado's emphasis on the need for an understanding of brain mechanisms in our thinking about the problems of society...
...I do not agree that the decision about a patient's treatment ought to be completely removed from the physicians charged with caring for the patient, nor do I agree that the seizures, or other brain pathology is irrelevant to the patient's abnormal behavior...
...THE ETHICAL PROBLEMS OF BRAIN MANIPULATION 367 fact things that you think ought to be done...
...Is that a technical limitation or an ethical position...
...And the results are that we are full of flaws...
...We are presenting this patient, not for debate, but to bring out some of the moral and ethical problems surrounding the violent patient...
...There's a great distance between being able to control behavior via brain stimulation, even with the most elegant internal computers, and restructuring society, its educational systems and so forth, by educating children...
...Certain issues come out of a therapeutic interest...
...The point then is how you decide between one value and another...
...RASMUSSEN: The human brain is much more epileptigenic than the animal brain...
...This new knowledge may change the phi losophy of our educational system, which is based on the sanctity of the individual, and on the assumption that an individual exists at the moment of birth...
...Peter Hospital for the Criminally Insane where he will be in permanent isolation, in a dungeon...
...Narabayashi, for instance, does amygdalectomies on children with unacceptable behavior...
...Scoville said, we could perhaps place, not a lesion, not even a chemical lesion, but a modification, a pharmacological modification of the brain function...
...In other words, most of these people on whom we operate have many superior characteristics that are out of order, making them sick...
...I think it will soon be out of their hands...
...The criticism goes: "These fellows [my colleagues and I] may get so they can stop murderous behavior in individuals...
...Just because Sweet invented that procedure and got that result, I don't see why his opinion as to whether he would operate is any more important than any person's in the room...
...This belief may be questioned...
...Where do you see the technology moving in the next 5, 10, 35 years...
...This is especially complicated in cases of mental illness...
...He has spent a year at a hospital for the criminally insane...
...Delgado is asking: how can you best get information to the child...
...I wonder if our enthusiasm about the knowledge the brain might give us might only be because we've done everything else for so long...
...I work almost wholly on humans, and we are more aware of the disastrous effects that sometimes occur in neurosurgery...
...This includes a right to property, but also a right to have a clean and safe environment in which to fulfill oneself...
...I happen to think that it's the courts that decide, but I would like to kind of pretend that .. . WEISS: I have noticed how cautiously all have moved at the beginning...
...Neville's [paper]: "The famous case of Thomas, the engineer, patient of Drs...
...It is not possible, however, to edu cate children with electrodes...
...GARDNER C. QUARTON, M.D., director of the Mental Health Research Institute and professor of psychiatry at the University of Michigan...
...We've always controlled people from the outside...
...Chalkley was then asked what forms of public policy might be employed to represent controls based on answers to these and similar questions...
...EHRENSING: I'm asking about your [Delgado's] concept of freedom...
...PRIBRAM: Very clearly...
...The man goes crazy all the time...
...That method won't work, you see...
...Your colleagues are understandably fearful of the responsibility that it engenders...
...Then they attempted to do a much more thorough electroencephalographic demonstration of his problem...
...But we don't do this in man...
...How are they to be related in the field of psychosurgery...
...One is the notion that the information we'll get from studying the biochemistry and physiology of the brain is somehow going to be significantly, perhaps vastly, more valuable than all the information we've acquired 368 over the years from more routine social and psychological observational techniques...
...What of psychosurgery and electrical brain stimu-opportunities and dangers do you see on the lation are now being employed, what are horizon...
...it only does things in interaction with the environment...
...But in the context of which kinds of manipulations of a person's environment could be ranked as closer to his person, it seems to me that no matter how we might communicate, short of telepathy, if someone moved a probe at the right place they would cut off all communication...
...We would like to find out from those much in scientific exposition as in a social and of you involved in these fields four kinds of moral interpretation...
...Vaughan then asked under what circumstances it would be appropriate to sub ject patients to an exploratory procedure...
...VAUGHAN: I agree with Dr...
...and then I would decide what I would do...
...Bering pointing out that the costs to human functions involved in brain manipulation must be weighed against the costs of not developing the techniques and employing them...
...Now these doctors have very safe, potentially very effective, and very applicable techniques of going into the head...
...There are times when the state rightly takes over...
...MARK: I just wanted to emphasize that the problem of frontal lobotomies is not—from a technical point of view—the same as we're dealing with here in stereotactic surgery...
...MARK: This case would be establishing a precedent...
...This makes for good guidelines—much better guidelines than now exist—guidelines that are vital in three areas...
...Well, if you can't kill yourself, can you cut out 98 percent of your brain...
...And we're afraid they will succeed, because then this information could be misused in other hands and lead to the performance of this kind of a pacification operation on those who are dissenting in society...
...Two, we can experiment with classical mental functions, such as memory, understanding, will, etc...
...WILLARD GAYLIN, M.D., clinical professor of psychiatry, College of Physicians and Surgeons of Columbia University...
...But as with the Ninth Amendment—which says that those rights not explicitly given to the U.S...
...GAYLIN: You remember Dr...
...The following edited transcript of the conference discussions has been issued as a Special Report by the Institute...
...WEISS: I think there are two problems here...
...But experiments on animals would hardly parallel changes of human behavior and emotion...
...Who ultimately gives control...
...I would say that the situation is analogous to playing a piano with a carpenter's hammer or having a concert artist sit down at the keyboard...
...Delgado expressed his belief that stimulation procedures are relatively safe, and that it is surgery that presents the problems...
...When they took her off therapy, they could not get a response...
...our information and our ability to do meaningful neurological tests that will focus, for example, on various aspects of the limbic system are still very poor...
...But there is something about this new technology that is different from most of the issues of public versus private interests which have preoccupied men in the past...
...Isn't that the broader question...
...lJ r. Pribram and others pointed out that aggressiveness cannot be understood only in terms of brain modification variables...
...We have very good methods of detecting lower brainstem problems and we have good neurological tests for specific problems at a cortical-thalamic level...
...This is a socialpolicy decision, perhaps proximately being faced here by the surgeons, but in the larger sense faced by our whole society...
...He might because of that reduced state be precisely the person who would tell you, "Yes, I am glad...
...EDGAR: I think Dr...
...When you stimulated his brain he seemed normal and during that phase, with your electrodes firing, he was willing to consent...
...if you change a person's language system, that also has pervasive effects...
...The problem with doing a reversible evaluation, Dr...
...By routine, I mean those not involving physical penetration of the brain...
...Dr...
...Why don't we now consider where we stand on electrical stimulation of the brain at focal points, as contrasted with the kind of stimulation the brain receives when the individual sits and reads a good book...
...In every paper today it is affirmed that all men have a private integrity and a right to humanity...
...Weiss asked THE ETHICAL PROBLEMS OF BRAIN MANIPULATION 373 whether control over longevity includes a right to suicide, and whether control over procreativity includes a right to have as many children as desired, regardless of the population situation...
...NEVILLE: What images of man and society, or man in society, ought we to have, in light of any special factors of electrical stimulation of the brain or of psychosurgery...
...This was not possible in the past...
...There has to be a principle for them...
...but they've tried every approach like drugs and psychotherapy and so on and so forth, and none of those things have worked...
...K. DANNER CLOUSER, associate professor of humanities and philosophy at the Milton S. Hershey College of Medicine, Pennsylvania State University, specializing in medical ethics, philosophy of psychology, and philosophy of medicine...
...A reformulation of the right to happiness, this point stresses the need for us to come to terms with the positive content of the concept of humanity...
...Sweet and Dr...
...We are, however, faced with the following specific dilemma...
...But what are they...
...The answer is, No...
...We should ask, What is man...
...Pribram explained the right to adequate medical care would be understood as part of the right to integrity...
...Suicide raises the question most clearly...
...Does the individual have the moral, legal, ethical, or social right to kill himself if he fully understands the nature and meaning of his act and weighs the consequences thereof...
...On the one hand, we have an available and increasingly more sophisticated technology, and this is paralleled by a rising alarm over everyday lives—not the pathologic kind that you read about in textbooks, but everyday lives...
...MARK: This man wants some treatment...
...Then we can deal with these global issues...
...and we're so clumsy at educating...
...How free was that decision and did you have personally, as the surgeon involved, any questions about that...
...You can say a surgeon can do it but you can't make him operate—ever...
...Up to now, man has been structured in a natural way by nature...
...MICHELS: What occurs in clinical situations has less to do with informed consent than with the power of transference in the doctorpatient relationship...
...ROBERT MICHELS, M.D., director of training, and associate professor of psychiatry at the College of Physicians and Surgeons, Columbia University...
...We do many dangerous, disfiguring, destructive operations...
...The second is a very strange thought that you have about the brain as more "intimate...
...He's built very much on the order of those huge tackles one sees on the Sunday television screen...
...He's been on the most intensive anticonvulsant and antidepressant medical regime, with absolutely no help whatsoever for his behavior changes...
...That's the general social and philosophical problem...
...You can have the body as a necessary condition and therefore certain things can be done and pre 372 vented by manipulating the body...
...For some of them the reason for operating was really the behavior rather than the seizures...
...I'm not sure that we are more into the mind when we're into the brain with a cannula or an electrode than we are with an emotion...
...London practices clinical psychology...
...Does the concept mean anything...
...Mark presented...
...You've got a cooperative patient, that's one of the purposes of the operation...
...What I'm hoping is that instead of destruction, as Dr...
...GAYLIN: Let us accept this as a basic premise: that we will always allow the individual an ideosyncratic response...
...But that doesn't alter the fact that we consider the pursuit of various mechanisms for the treatment of cancer to be authentic and legitimate...
...Fourth, behavior: one is through the environment, what is the rationale for undertaking these the second (our subject) is through the brain...
...And is that an accurate description of what happened...
...She gave it, but under the circumstances, she would have consented to anything, likely even decapitation...
...GAYLIN: Dr...
...One is, What do we do to Arthur...
...president of the International Society of Psychosurgeons...
...Our answer will tell us what his rights are...
...The decision was made: they went to the mother and said, "We are going to court and seek a judgment to allow us to keep your daughter in therapy...
...There's another side to it, which is the assumption that it would be preferable consciously to program man, and that it is deplorable that he is sort of randomly and chaotically programmed by our current lack of precise knowledge of the effects of our inputs into the nature of man—genetics, genetic recombination and mutation...
...we are constructing his brain...
...It has to do with the capacity and the behavior...
...Vaughan pointed out, is its expense in money, time, skilled people, and equipment...
...Present technology may give us a new understanding about how education modifies children's brains...
...The supposition that somehow the brain is more intimate an environment than the others, I just don't see...
...Dr...
...I think that electrical-stimulation technology is more conservative than surgery...
...Pribram to present his position on a biological bill of rights...
...he remembers the successful animal that has given him the information he was looking for...
...The problem for both is that reason itself has become disreason, a distortion of reason...
...NEVILLE: I have no stock in the geographical metaphor except in terms of ordering closeness of control techniques...
...Does that present a particular ethical issue to you that you would care to share with us...
...MARK: I agree that public participation in certain medical decisions is desirable as long as the public participants are knowledgeable and honest...
...Not unless experiential inputs modify our brain and give us that freedom...
...WEISS: Based on what you've said, it has become more and more clear to me that our basic question is whether what's happening today is different in kind and in degree from what we've been doing since the beginning of civilization...
...There is a very limited number of neurosurgeons in the United States, and as far as the number that does stereotactic surgery is concerned, it's even more limited...
...NEVILLE: The concept of justification is ambiguous here...
...they do not raise sophisticated ethical issues...
...And we don't get useful information in terms of brain functions from the great majority of such people whom we would hope to improve somewhat by surgery...
...In this way I can grossly change his behavior...
...They asked the daughter...
...We should also try to clarify the biological bases of the potentials of the in dividual and what effect they have on demo cratic beliefs...
...There are lots of ways of defining privacy but it seems to me that in the social context, privacy is something that people demand for certain spheres of their life, and that society grants...
...I'm quite confused myself about the particular values used for defining what ought to be recognized as the private sphere...
...Now it seems to me that our technical abilities at the present time are like those of a skilled craftsman who's trying to repair the sounding board on a concert grand piano when there's a giant crack in it...
...that's how we would be able to adjudicate this question, by looking at what the principles are that make you put these down...
...Or what might they be...
...The problem of decision-making here seems to me that of trying to fit these various criteria together relative to the alternatives of control techniques...
...Sweet's paper, because of the implication, where he says, "it has been a rude surprise to many of us concerned with such patients to find that our procedures on them have evoked the most vitriolic criticisms we have met in our professional careers...
...SCOVILLE: With your vast experience, Dr...
...SCOVILLE: What is this man's attitude toward seeking treatment...
...Mark discusses and assesses some of the major techniques and uses of psychosurgery...
...Delgado doesn't speak for the situations in which he is ethically unwilling to put electrodes into the brain to educate...
...In the review of grant proposals, funding agencies ordinarily count on the grantee institution to provide review procedures for the propriety of the funded research...
...Feeling that some of these very practical but abstract questions could be best ad dressed with references to particular cases, the final session of the conference was de voted to a case presentation by Dr...
...Bering is discussing—the hyperkinetic child that is destructive of furniture, others, and himself— may have to be restrained constantly in a bed with all four limbs tied down so that this incessant tendency for destruction will not occur...
...There is a further difficulty, which is perhaps even greater, in gaining the knowledge necessary for using a brain-manipulation procedure effectively and safely...
...By stimulating the brain with electricity one can start and stop certain activities...
...You're closer to me, I'm interested in you...
...This man has gone back to the Veterans Hospital in Minnesota...
...and three, the criteria of respect for the persons to be controlled...
...The mother's argument was that the girl had survived 30 years in this condition, that a cure of her Parkinsonian disease would force her to come in contact with a civilization that she, to all intents and purposes, did not know and to which she had never adapted...
...I'm talking now like a cop, or like a citizen who could get beaten up, or like an airplane pilot who doesn't like people walking around with live grenades...
...And possibly the randomness and our lack of control over this system of informational input into the nature of man, this postgenetic rather than genetic random input, may also not be unfortunate...
...In the past, the brain was considered an unreachable entity, but today we can look at the working neurons...
...LONDON: First I want to agree—urgently agree—both with what Dr...
...WEISS: I would say that there is a private being to man...
...I might come up with the conclusion: . . . full-steam ahead...
...The child was 50, the mother was 80...
...Then the question is, If a patient expresses the desire for some "reconstruction," do you say it's "therapy...
...I don't know whether you have a kind of spatial image, that maybe the soul is at the center, the brain is closer to it, rather than the outside...
...Ideally, the person to give consent is the patient after he is cured...
...Dr...
...LONDON: Dr...
...Unless the rate of firm knowledge, and the standards for defining what firm knowledge is, can accelerate at the same rate as the improvements in the technology, the situation that will arise more and more often is very, very dangerous...
...PRIBRAM: What's your answer...
...VAUGHAN: Who decides what is an appropriate and justifiable physical manipulation...
...Experimental research of the brain may change the classical question of philosophy, which was, What is man...
...CLOUSER: How does one decide what is really therapy and what is actually reconSPECIAL FEATURE struction...
...but the problem is the klotz factor in surgery...
...Sometimes we would not like to have our brain be private, if, in fact, we can be freer, better, or cured of disease by intrusion...
...Just to give you an example of the kind of activity he engages in when he has his "violent attacks," he went into a rage when a judge in a county court said that he was going to confine him for three months because of repeated traffic violations...
...One, the criteria of efficiency, on the one hand, and whether or not the technique works...
...VAUGHAN: Exactly...
...EHRENSING: I bet not too many malpractice suits resulted from that...
...Is he asking for medical treatment or surgical treatment...
...Three, we can relate mental functions to chemistry and to neural structure...
...The type of due process that we use for handling criminals and the type of due process that we use for commitment procedures may not exhaust the range of actions that society might wish to take to deal with problems involving value contradictions...
...But here you have a case where no matter what you did there was injury done...
...Or 97 percent...
...A list of participants at the conference appears boxed, on pages 365 and 367...
...PRIBRAM: This is the case where you really need to go to the public...
...He responds to very small changes in his environment...
...Third, we need to know which areas of the brain are paired so as to produce or suppress activities...
...Ethical, because we should not influence the brain in such a way that the individual lacks capacity to react, and technical, because by brain stimulation we cannot provide information...
...Two main questions were raised...
...First, the scientific status: how do we evaluate scientifically the nature of specific brain functions...
...DONALD T. CHALKLEY, chief, Institutional Relations Section, Division of Research Grants, NIH...
...If in an aggressive person a lesion is made that renders him a very placid individual, you've actually changed this person...
...Unlike compulsory education, unlike vaccination, unlike the traditional domain of conflict between the state and the individual, the arena of discourse here is the executive apparatus of the individual...
...You suggest further that they're the fruit of an optimal range of complexity and that if one is either too complex or too simple one loses options...
...MARK: I wonder if some of our ethical dilemmas aren't posed by the limitations of knowledge that we have about the kinds of cases we're dealing with...
...Second, what is the minimal diagnostic requirement that we can place upon the clinician for assessing the extent to which he is really dealing with brain dysfunction in a patient, and for the relative wisdom of cutting him open, whatever that may mean...
...I haven't thought of it as optimal, however...
...Are we in fact dealing with a disease process, and how is it defined...
...With the physical manip ulation of the brain we usually accomplish a great many other things as well, and some of these are undesirable...
...VERNON H. MARK, M.D., director of the Neurosurgical Service at Boston City Hospital and associate professor of surgery at Harvard Medical School...
...CIALLAHAN: Could you perhaps say something about psychosurgery as such...
...HERBERT G. VAUGHAN, JR., M.D., professor of neurology, Albert Einstein College of Medicine, whose special research is the development of a visual prosthesis through electrical stimulation of the brain...
...SWEET: I would like to get what your thoughts are about the validity of specific criticisms to which my colleagues and I have been subject in our own institution...
...LONDON: The real issue is this: you have the capacity to go into this man's head, physically and directly...
...It is easier to have an electrode implanted than to take a course in some subject...
...Our criterion, for all its ambiguity, is that if the patient is rational and conscious we try to do an operation for which he is glad...
...The mother withdrew the objec tions...
...He is a terrible potential menace to society and to himself...
...VAUGHAN: My experience as a neurologist is that people do consider the brain to be one of the areas in which the possibility of a surgical or physical procedure is most feared...
...First, what kinds of techniques lemmas your present techniques raise...
...We must beware, however, of assuming that a human infant is more of a tabula rasa than he is...
...A person chooses to embrace and make a lover of his cancer: we allow him to do that...
...Is there any privileged status for what man previously has been...
...Delgado is going to make that technology so much easier that people without your sensibility and without your skill are going to be able to do that too...
...Such a child is, of course, totally untestable in terms of any refined testing techniques as to his current potential...
...You put in information in two senses...
...His papers state that afterward the children behave better and that there seems to be no intellectual deterioration...
...But I can well understand a man saying nobody's closer to him than God...
...Under what circumstances do these two extreme alternatives have to be considered...
...We have the power and the knowledge to understand how "man" is constructed inside the working brain, and to manipulate these building blocks that construct man...
...These are obviously difficult to separate in the kinds of cases we are discussing...
...Chalkley, that's a very flashy answer, but I don't really think it helps the problem...
...In other words, is this a research-direction for man that you think one ought to take...
...Is that the question you're asking...
...The neurology of behavior unfortunately is still in a rather embryonic state...
...We've followed him now for two and a half years with the question of doing temporal-lobe surgery...
...The question you are raising seems to be this: how do we know that the patient is not under the influence of the electrical stimulaSPECIAL FEATURE tion in some minor way a month hence, and if he were under this influence would his consent not be in some way spurious...
...Fourth, we need to develop techniques for connecting these paired areas with feedback information so that undesirable behavior can be suppressed and desired behavior stimulated...
...For me there are two questions...
...Or should this choice in all instances be left to the individual...
...Third, if you had unlimited time, talent, sions, peer review, educated sensitivity of the and funding at your disposal, what do you practicing surgeons and physiologists...
...The patient has never had a history of a seizure, except for one very peculiar episode that occurred when he was II years old and in which he seemed to have done some very unusual things that he didn't remember and that didn't make much sense...
...Delgado's caution to us...
...He also pointed out the greater flexibility, in cost terms, of the electrical stimulation procedures because their effects for the most part are reversible— while psychosurgery is irreversible...
...But the technology is getting easier and easier to use...
...Second, when is consent informed...
...And you answer this by going into the brain and discovering how it reacts...
...Nor is the counterrevolutionary problem to reaffirm the claims of reason...
...It seems by electing to place the final responsibility in a court of physicians, you've created the web in which you are now struggling, trying to define the problem as epilepsy, a medical-scientific term, rather than in social-ethical ones...
...And we are making a more intensive effort to find out what happens after the procedures than was the case two decades ago...
...there is an optimal middle range in which the number of options is optimized, so to speak...
...Before permanent lesions are made, however, trials should be made with methods of temporarily suppressing brain function, for instance through cooling or electrical stimulation...
...The test comes three months later when you say, are you glad you had the operation...
...To what degree can we predict the consequences of this or that lesion, given our present, or indeed foreseeable, scientific knowledge...
...Pribram suggested that the problem of privacy ought to be formulated in terms of the right to integrity...
...With respect to biology, this includes a right to control one's longevity and procreation...
...He is not an epileptic in any definition of the word that we presently use, although he certainly is close to it in terms of his behavior, and in terms of a number of other facets that he has...
...Opportunity includes both the right of each to take equal advantage of the physical and social environment, and the right of each to profit equally from its resources...
...How many incompetents are there, or how many people who may be competent in other areas THE ETHICAL PROBLEMS OF BRAIN MANIPULATION of clinical surgery but are not aware of their limitation of knowledge in this area, who are not aware of the secondary effects of the intervention but realize that their technical skills are absolutely adequate for them to go through the technical motions of the clinical procedure...
...This conception may be dangerous because it changes the conceptions of freedom, identity, and integrity...
...When the mother was out of the room she begged them not to take her off the therapy...
...This pneumoencephalogram was repeated at a dif ferent hospital, and this confirmed the fact that this man had a very abnormal temporal horn on the left side...
...So you come up with this kind of dilemma because they come up with what Dr...
...We need to understand man from his cultural outside and also from the inside of his central nervous system...
...The beauty of a bill of rights is that the right of the individual becomes balanced against the right of his social group and his society by the legal adversary procedures that take place over the years...
...SCOVILLE: It's a veering from superiority to mediocrity that we surgeons worry about...
...But you're not going to be able to change the effect of an operation by making a decision...
...GAVIN: Coming from a long line of pessimists, I see a few things that I have to express here...
...But then, perhaps he was under undue persuasive pressure...
...SCOVILLE: With all due respect to Dr...
...There is a question, then, of assessing the value of the state versus the individual...
...SWEET: Yes, I think this is an accurate summary by Dr...
...The fractional psychosurgical lesion is a transitional stage in developing chemical alterations and, of course, possible electrical stimulation techSPECIAL FEATURE niques...
...Now the legal responsibility lay with the mother...
...Delgado was suggesting that by the exploration of the brain through the techniques he's outlined elsewhere, we can learn more and can enhance our current routine techniques of education...
...GAYLIN: Professor Weiss raised what I do think is an essential question...
...CHALKLEY: I was thinking of the devices man has approved for the treatment of violent behavior in the past, including pain, torture, imprisonment, institutionalization, surgery, external electrical stimulation of the brain, chemotherapy, and psychotherapy...
...They had a Parkinsonian case, who was 50 years old...
...The human brain has a particular genetically determined structure providing it with certain capacities that unfold during the course of interaction with the environment, both external and internal...
...Where is the line...
...Can we not start from those minute pieces of evidence 370 and see whether we can't force some kind of conclusions about man, what his exterior is, and relate this to his privacy...
...the aim is rationally to program man who's already being programmed, who now is being programmed chaotically without conscious planning...
...JOSE M. R. DELGADO, M.D., professor of neurophysiology at Yale University School of Medicine, whose experiments in electrical brain stimulation have received wide discussion and whose book The Physical Control of the Mind raises many of the issues discussed at the conference...
...So we need to be concerned with a need for an incremental adjustment of the person to whatever procedure is to be performed on the brain...
...Another time he put his hands through the wall when he got angry at the Minneapolis Veterans Hospital, and so frightened his doctors and attendants that they refused to come into the room any more to see him...
...Now I think most of us have a much better idea as to the need for study of many more aspects of the whole individual before an operation...
...Delgado said about the problem that becomes apparent to all of us...
...One of the things that might come out of a study like ours is a way of designing alternate social institutions that could be used to make decisions in cases like the one Dr...
...in Violence and the Brain, written with Frank Ervin, M.D., Dr...
...The first right is that of equal opportunity...
...The frontallobe operations were in the beginning very inexact...
...MICHELS: The case history we're talking about here is not the case of Arthur P. but the case of Drs...
...In your own writing you make a strong point about the need to reconstruct man by essentially educational, informational means...
...Dr...
...This rather startled the hospital...
...Dr...
...This is understandable...
...This obviously complicates the ethical issues...
...We cannot educate children with electrodes...
...The issue that arises is not how many fancy neurosurgeons there are who know how to use this technique...
...In trying to cure someone or to make him better, how would you define health...
...Rasmussen, have you operated on people with grossly pathological behavior but without overt seizure formation...
...Sweet would care to comment on the quote from Dr...
...Though it's a simplistic explanation, this is my criteria...
...In that situation, you'd throw the sounding board away and get another one...
...That kind of problem is distinct from the sort that arises out of society's interests in controlling behavior, where there is not nec essarily a pretense to making the person better, but just protecting society from the person, or from certain aspects of his behavior...
...We have not done so up to this point because we are not sure of our diagnosis...
...DELGADO: The main implication of brain research for education is that the research will make available unique information about the neurological mechanisms...
...It was possible for a number of people, who were not surgeons, to do frontal lobotomies...
...president of the Institute of Society, Ethics and the Life Sciences...
...RASMUSSEN: If you want to make a bad decision instead of us, that's one thing...
...Delgado and others are doing...
...He can't do anything without taking some risk...
...I like the line in Dr...
...Are there any...
...We may come to the conclusion that there is indeed a substantive difference between entering the brain and manipulating it artificially as distinguished from manipula ting it with ideas...
...DELGADO: I think that there is something new...
...He also has injured people, usually in response to minor provocation...
...Why don't they do that...
...WILLIAM BEECHER SCOVILLE, M.D., clinical associate of neurosurgery at the University of Connecticut Health Center and associate clinical professor of neurosurgery at Yale University Medical School...
...One of them, as I understand it, did 16,000 frontal lobotomies, using what was euphemistically known in neurological circles as an "icepick...
...Delgado has said several times that one should not use electrodes to educate children but merely to find out what goes on in the brain as a consequence of other forms of education...
...When something goes wrong with that experiment the animal is discarded and forgotten...
...He pointed out, however, that the rules of precedent are not always binding...
...Therefore, we are limited by the building blocks at our disposal...
...THE ETHICAL PROBLEMS OF BRAIN MANIPULATION MARK: At the present time he has never had a seizure...
...I'm not satisfied with the way in which our present civilization is behaving...
...But it is still brain surgery and entails the same risks, even though they're much smaller, as other kinds of brain surgery...
...He asked, Is there something substantively different about this method of modifying human behavior over traditional methods...
...I thought increase would always give us greater value...
...First, we need to know which parts of the brain are involved in various kinds of behavior...
...He said the greatest moral problem arises out of the fact that the techniques of manipulating the brain are relatively easy...
...But I suspect an argument could be made that changing the brain affects more basic things than changing one's language...
...THEODORE B. RASMUSSEN, M.D., director and professor of neurology and neurosurgery, Montreal Neurological Institute, McGill University, a pioneer in neurosurgical treatment of behavior disorders associated with epilepsy...
...PRIBRAM: A bill of rights...
...secretary of the Institute of Society, Ethics and the Life Sciences, and codirector of the Behavior Control Research Group...
...First we should try psychotherapy SPECIAL FEATURE and drugs, the traditional psychiatric approaches...
...After diagnosis indicated that destructive lesions be made in his brain, his wife was asked for consent...
...What are the this conference to introduce the ethical and worthwhile goals for psychosurgery and elecvalue issues into the technical discussions of trical brain stimulation...
...Vaughan quite correctly calls the specious requirement of a seizure, or a definition of epilepsy...
...Is there, within each of us, perhaps inborn, some fear that requires us to protect ourselves against encroachment upon the brain...
...She would face complete reeducation...
...It's important to keep that in mind...
...Delgado points out, is becoming an increasingly dangerous situation...
...Because epilepsy is not a matter of the .. . MARK: EEG interpretation...
...NEVILLE: Aren't you [Dr...
...Literally thousands of people have had needles inserted...
...Do you mean that three distinguished physicians, colleagues, professors of the same medical school, who I presume know all of you personally, people you see in your daily rounds, have no connection with the program...
...In some respects, the moral problems of these techniques are the same as those of any techniques that involve radical surgery...
...But one could look at the brain and any other part of the body as outer...
...First, what happens to the concept of informed consent in the context of asking what kind of man we want to construct...
...If you don't like the result you're stuck with it and it can only be changed by making the lesion larger or another somewhere else...
...Would you go on then to say that a physical manipulation of the brain is moral if it moves the complexity toward that optimal range, and that it's objectionable if it moves it in either direction away from it...
...For example, when he tried to call Frank Ervin from Minnesota and couldn't get him on three or four different occasions, he called me up and said, "I wonder if you could get Frank Ervin...
...On the other hand, if a violent person has a normally functioning brain—then he doesn't need therapy—be it surgical or medical...
...But it seems to me there's another question: does a person have the right to informedly consent to anything that might be done to him...
...If he's glad he had it, we are glad...
...This man has been studied extensively at various hospitals...
...This man consented to the surgical procedure when he was under the effects of this stimulation, when his behavior, in general, was far more socially acceptable...
...The other point is that the environment in terms of which an individual is prepared to cope with infringements on his personality is more external than the brain...
...But they've all had unequivocal temporal-lobe seizures...
...We are concerned with organic brain diseases...
...DELGADO: The inviolability of the brain is only a social construct, like nudity...
...Neville of that case report...
...The revolutionary problem was not, he asserted, to promote irrationality over a moribund rationality...
...MARK: Stereotactic surgery is one of the lowest-risk kinds of neurosurgical procedures in use and one of the easiest as well from a technical point of view...
...Rasmussen raises a sort of Heisenberg principle of neurosurgery, if you will: when you put an electrode into the brain, from that point on you are of necessity exploring an abnormal brain...
...When was he in his `right mind...
...In my view, we need an approach to defining health that would allow one to make all sorts of changes in a person's nature if one could show that this was more valuable than the previous state...
...Again, suppose the social attitude is strongly positive...
...That capacity has absolutely nothing to do with epilepsy...
...As an introduction, he commented on the revolutionary fervor of the 1960s, and on the counterrevolutionary interest in control posing the very problem for our conference...
...Although as therapists we may know in a particular case what we want to accomplish—relieve pain, stop sei zures, induce a schizophrenic to acceptable modes of behavior...
...Right now, which is closer to me, this cup or you...
...GAYLIN: It seems to me that this is a constructive thing to come up in the meeting...
...If we address ourselves to the hyperactive child and ask, as Dr...
...Now if we take out all the social aspects (i.e., the purely socially generated violence) and study only the brain-related violence, we're still faced with a tremendous dilemma because our information about the specific kinds of brain deficits, and how they're related to specific behavior, is still limited...
...You have to justify your rights...
...There are whole hosts of human conditions, some of which may be related to brain problems and some of which may not, which may engender aggressive or even violent behavior and to say that one kind should be treated medically, let alone surgically, presupposes a knowledge about the given individual...
...You have to tell us why these are rights...
...WEISS: I think you're mixing up a necessary with a sufficient cause...
...Neville is...
...Someone else could come along holding up eight other rights against yours...
...The question has been raised of the privacy of the brain in the wider environment...
...Are we asking him to tell us how his behavior is to be altered...
...I would like to redefine freedom as the use of our intelligence within frames of reference given by culture and by experience...
...but it doesn't follow to identify the body with the mind...
...LONDON: I couldn't agree more with Professor Weiss about the issues raised...
...may be used to restructure a different kind of education, and therefore to create a different kind of child...
...Therefore, while we're waiting for the basic knowledge, the urgency is to set up certain reasonable protections and guidelines...
...And second, do you see any validity in or a future for the ideal of freedom...
...Nobody knows whether or not any of the patients with ingoing electrodes or instruments passed through the brain have ever developed seizures as a result of this— because nobody has asked this question...
...Mark and his colleagues won't...
...DELGADO: I would like to emphasize that my position is not aggressive but conservative...
...In order to secure a more rational public life, in the face of advances in life science and control technology, and in recognition of current political forces, Dr...
...CLOUSER: When we talk about justification for procedures, we give a reason showing that it's to somebody's benefit...
...Bering noted that much of the difficulty in costing out these procedures is that their results are so poorly known...
...We don't ask children whether they want to be educated...
...The way by which external things affect a person is mediated finally and always through his brain...
...Through sensory inputs, and through brain manipulation, we are really constructing and modifying the materials that form the neurological basis of man...
...I think we would have had a very serious problem if he had given consent only in periods in the poststimulation cycle when his behavior was calmer and more socially acceptable than usual, and if he had refused to do so when he was in a belligerent, fighting mood...
...In other respects, they're the same as those of any kind of behavior-control devices...
...That is true in almost every case...
...CHALKLEY: I would just like to describe a somewhat more complex decision that recently was forced on a hospital that will be unnamed...
...GAYLIN: I presume that because you're only considering violent people who have temporal-lobe epilepsy and would be candidates for surgery even if they did not show violent behavior, that he does not therefore fall into your category of an operable person...
...But they don't follow from the arguments given...
...Delgado, agreeing with Dr...
...Irrationality is something else again...
...director of the Behavior Control Research Group...
...Second, we need techniques to identify electrical and chemical events in the brain associated with the relevant kinds of behavior...
...If I put an electrode in the lateral hypothalamus and then stimulate that only at certain times when the animal is in a certain setting, I'm putting information into that animal's brain just as much as I'm putting it in the computer...
...First, you have given us a social meaning of privacy, and you still haven't faced up to the question of whether there is any private, nonsocial, nonpublic meaning to it...
...And when you have the combination of easy technology and difficult acquisition of knowledge, you have deadly possibilities...
...GAYLIN: Exactly...
...The old-fashioned total lobotomy, as we call it, was simply a lowering to mediocrity...
...And when you read a book like 1984, what disturbs you about it is the blandness of the creatures—not their being controlled...
...Citing cases involving both malpractice and experimentation without sufficient consent, he illustrated various precedents for medical and experimental legal limitation...
...If these fail we could then consider some kind of direct brain manipulation...
...Our laws say no...
...It has absolutely nothing to do with an abnormal EEG...
...Fortunately, the staff persuaded him to give consent when he was not under the influence of recent stimulation...
...Delgado and Dr...
...Arthur is six feet four and a half inches in height and weighs 267 pounds...
...SWEET: I think that the effort here would indicate that the process of giving informed consent can be a very complex one...
...RASMUSSEN: We have a fair number of patients with varying degrees of this kind of episodic aggressive behavior, associated with temporal-lobe seizures...
...We're looking for some way for him to express his private side in order to redefine what is to be publicly done to him...
...Delgado, you said in effect that for the first time man has the capacity to enter into or to control the mind...
...Individuals and society may not always agree...
...He answered that the most obvious and forceful form of control is the law...
...Under these circumstances [in the case of Thomas], however, we felt that we were in a very strong position...
...or whether it's some funny mixture...
...Am I reading you...
...It's not a purely political matter...
...Behaviorcontrol techniques, especially these, seem to me to be altering the environment to make possible certain personal actions or certain personal continuities, careers, certain highly prized human emotions and the like...
...The principal reason, I'm sure, that hanging was in use for so many years was that torture was more expensive...
...BRUCE HILTON, associate for publications, Institute of Society, Ethics and the Life Sciences...
...He's been seen by a number of very competent neurologists, neurosurgeons, psychiatrists, and has received psychiatric treatment now for about six and a half years, of almost every variety...
...But it's not necessarily the wisest course to exercise the right...
...A patient isolated in a hospital, perhaps tied down, is not in a position to have his responses to a natural social environment observed...
...This is an important question to which we should address ourselves...
...You are saying that options are the fruit of complexity, not of simplicity...
...As the technology moves faster than the basic knowledge, we cannot wait for the basic knowledge because the technology is going to outstrip it...
...It's a simple technical fact...
...Now you combine this with recent conditioning of the public by the promises in popular magazines of this new molecular and brain biology, and you have a very frightening thing, namely, a kind of openness to the alternative of turning people into vegetables...
...PRIBRAM: With mental cases, you generally shift to giving satisfaction to those who love them the most...
...As far as my own willingness to work on human beings is concerned, I'm prepared to implant electrodes in the human brain only when the individual is in a serious, approaching what I would call a desperate situation from the standpoint of relief of pain on the one hand, or when his behavioral 366 manifestations are so gravely at variance with accepted behavior that society probably can't allow him to move freely...
...The randomness of that system may not be unfortunate...
...It's very unlikely that stereotactic procedures are going to be done by people other than neurosurgeons...
...people work on it from the outside...
...If an individual with a normal brain is criminally violent, he should have legal rather than medical attention...
...The fact is that we don't really feel he has epilepsy...
...If you can't kill yourself to relieve pain, can you destroy your essential humanity to relieve pain...
...staff director of the Behavior Control Research Group...
...Delgado takes the public side to exhaust the whole of what a man is...
...He is very sensitive not only about the fact that he faces this kind of future, but also about the fact that he's going to be imprisoned with a group of people who he feels are morally quite different...
...You have a technology that permits you to address that directly...
...two, the criteria of social costs...
...That is, the seizures were relatively unimportant...
...And you're cursed with ingenuousness, and the fact that you know that this capacity is developing in your own work...
...It is this right that most of all bears on the dangerous implications of behavior control...
...Vaughan on the need for experimental justification for brain-modifying procedures, outlined the following five areas in which more experimental knowledge is needed...
...BERING: A very important point that has not been brought out is the difference between a surgical procedure on the brain and electrical stimulation of the brain...
...Furthermore, the technical aspects of doing stereotactic surgery, while fairly straightforward, are still time-consuming, and this puts it into a different category, for example, from the frontal lobotomy op erations done during the 1940s...
...DELGADO: Freedom is only a relative concept...
...Could you comment on that at all...
...Vaughan and Dr...
...SWEET: The kind of patient Dr...
...He had numerous brainwave examinations that showed borderline changes...
...HAROLD EDGAR, associate professor of criminal law, Columbia University Law School, specializing in law and the life sciences...
...ROBERT NEVILLE, associate professor of philosophy at the SUNY College at Purchase, and associate for the behavioral sciences at the Institute...
...What are the unintended and unanticipated consequences of the work Dr...
...The question rather than, What is man?, should be, What kind of man are we going to construct...
...Pribram cited studies with cats and monkeys in which identical brain operations produced opposite kinds of behavior, where the distinguishing variable was the social relationship between the animals in the group or between the animal and the experimenter...
...So that if he showed no violent behavior the nature of his epilepsy would not warrant surgery...
...The other is, Who decides what we do to Arthur...
...p THE ETHICAL PROBLEMS OF BRAIN MANIPULATION 381...
...and then, at a subsequent time, when much of his other behavior was not socially acceptable, he was still amenable to this procedure as a consequence of the conversations he had at that time...
...I don't really give a damn what Sweet would have done, SPECIAL FEATURE because the reason I would go to Sweet is to know whether he could get the results with surgery that he got under stimulation...
...It is evident that in many critical respects we know a great deal less about brain functions than we ought to know, or than we want to know, and the lack of knowledge makes the question of intervention very, very much more doubtful than it would otherwise be...
...That stretches my credulity considerably...
...I'm sitting here in the airport in Minneapolis and I have a live grenade in my pocket and if he does not call me back at this number within ten minutes, I'm getting on the plane, going to Boston, going to his house on Kendall Common Road, blow him and his family and myself up...
...GAYLIN: But you see you've been using the wrong criteria...
...PRIBRAM: Some did actually use an icepick on some patients...
...EHRENSING: I wonder if Dr...
...I think that the present techniques for making surgical lesions will be replaced with chemicals—chemical lesions...
...We shouldn't operate on human beings until we have that knowledge...
...Prisons are running out of space...
...We should improve the society in which we live...
...A quick lesion is a lot less trouble than a careful experimental trial...
...In light of the need for developing better techniques, I too want to congratulate Jos6 Delgado...
...Therefore, I think that today we have SPECIAL FEATURE new possibilities to study the brain technically, theoretically, and practically...
...Sweet what he would have done if that chap on stimulation consented and without stimulation refused...
...A case was cited of a man who had attacked his wife with a meat cleaver...
...What are the moral diinformation...
...With analogies drawn from the development and use of the cardiac pacemaker and the imminent development of a visual prosthesis, he indicated both economic and personal costs on both sides...
...Once you've said that, we can't get any farther...
...Third, once the diagnostic criteria are established, what is to be done inside the person's head, and who is to do it...
...KARL H. PRIBRAM, M.D., professor of psychiatry and psychology, Stanford University Medical Center, a neurosurgeon and neurophysiologist interested in social biology, and author of Languages of the Brain, which sets out a theory of the neurophysiology of behavior...
...We are forming the individ ual...
...The issue which we are all explicitly joining is whether it's justifiable, and under what circumstances, to radically alter the nature of the individual...
...Fifth, we need to find out what might be the secondary effects of manipulative procedures...
...A certain amount of guessing about what the patient would want if he were cured is always involved in proxy consent...
...He then proposed an order of treatments according to reversibility and least potential damage to the psychological structure of the individual...
...That would be a problem partially because the reconstruction would proceed from somebody demanding something, saying, I would like so and so...
...We know a little about this now, but need to know a lot more...
...Are you free to speak Chinese, or Russian...
...Bering has very correctly done, what is the eventual cost to this child in terms of his impairment of learning after the procedure is done, I think we also have to ask the question, What is the impairment of learning in this child because of his disease process...
...There are, however, immense practical difficulties in overseeing concrete medical and scientific practices...
...Delgado is making that have not been discussed...
...He's asking what changed that man's mind...
...But the review boards of institutions generally examine only whether the proposed research accords with the canons of good science...
...It seems to me that once you deal with the desperate need for therapy of some kind, you can try various things that would more or less be unacceptable in other controls...
...But our ability to look at and test the limbic 376 system—in the broad functional sense—is extremely limited, even when gross pathology is present...
...The social setting must also be taken into account...
...That is, the brain is the one mediation structure that cannot be avoided...
...We pass ventricular needles into the brain for diagnostic purposes a number of times every day in every neurological center and we have pretty good evidence, from following these patients for other reasons, that a single penetration probably has one chance in a million of producing seizure tendency...
...We need a convergence between both approaches...
...EDGAR A. BERING, JR., M.D., chief, Special Program Branch, Collaborative and Field Research, National Institute of Neurological Diseases and Stroke...
...The physician is always on the horns of a therapeutic dilemma...
...Psychosurgery and electrical stimulation of the brain are among the most dramatic of new technologies for controlling human behavior...
...NEVILLE: I suppose the kind of image I had in mind was one of layers of mediations...
...DELGADO: No, this is the wrong notion...
...Through the environ ment, we are really modifying the structure and substance of the brain electrically and chemically...
...or if not desirable, what is your prediction DELGADO: There are two ways to control about the long-range developments...
...MARK: Exactly...
...ORLOV: I'd like to ask Dr...
...Then they're going to add two and two and get four, and say, "There's lots of people who act in lots of crazy ways and these doctors can't find anything wrong with their brain, their glands, or with their bodies...
...THE ETHICAL PROBLEMS OF BRAIN MANIPULATION —ethically, I wouldn't do it--but practically, I certainly could educate a child by putting an electrode in the lateral hypothalamus and then selecting the situations at which I stimulate it...
...What are the urgent imperatives...
...The procedure is essentially reversible but a surgical lesion destroys part of the brain and is an irreversible, permanent anatomical change...
...You can't just say here's a right, here's a right, here's a right...
...I am not convinced that communication is less "entering into the mind" than insertion of an electrode...
...The discussion then focused on the problem of consent...
...General, they come to us, a committee constituted in a different way, and get an alternate view to take back and use in the discussion in Boston...
...Or 0.38 percent...
...But suddenly gigantic conclusions are brought out about ethics, freedom, rights, education...
...This is perhaps the residue of the Aristotelian conception of the soul...
...There's something appealing about that...
...One, we are dealing with the brain directly, circumventing sensory inputs...
...Sensory inputs have intracerebral correlates that were unknown in the past but may be investigated in the present...
...SWEET: The innovator of manipulative techniques in man, seeking to apply the information that his colleagues in the animal laboratories have learned, quickly comes up against the realization that these gentlemen seem to forget about the animals that die...
...As commonsense civilized men, all recognize that individuals have irreducible privacies, inexpugnable rights, that they are beings who are irreducible and unduplicable, and that the only question is, What do we do about their public dimension...
...Ervin, Mark and Sweet, illustrates the point: when under the influence of calming electrical stimulation he consented to psychosurgical procedures for destroying certain brain cells, but when the effects of the stimulation wore off he refused consent...
...It suggests that there's a possibility society can develop techniques for providing due process in cases that don't fit the old categories...
...Sweet has enor mously simplified the ethical problems here by his insistence that he will work only from the therapeutic point of view...
...PRIBRAM: I must correct the notion that you don't put information into the brain when you stimulate it...
...Couldn't a seriously damaged, lobotomized patient be reduced to that very primitive acquiescent point where his definition of being glad would not be one you would be happy with...
...The fourth of the basic rights is that of humanity...
...Numbers of criminals are increasing every day...
...He is an expert in both armed and unarmed combat...
...This is a redefinition of liberty...
...But we now are talking about behavior control of various sorts and let's ask for some general guidelines as to where, whether the person wants it or not, we find it morally acceptable or reasonable, and where we are prepared to offer it if the patients do want it...
...Both Dr...
...In less than five years Dr...
...DELGADO: Let me repeat what I've said...
...Patients will consent to absurd things while appearing to be informed about what they are doing...
...That's what's going to happen...
Vol. 20 • July 1973 • No. 3
