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Awareness of the ambivalence of scientific Deep Brain Stimulation
Neuromodulation Therapies for Psychiatric Disorder and their Ethical Implications considerably over the last few decades. Prob- lems associated with scientific and technologi- Depression refers to a set of prevalent, extremely debilitating disorders that can be character-
cal advancement and their possible but some- ized by a triad of symptoms: extreme anhedonia (complete loss of pleasure from previously
times uncertain consequences are accordingly pleasurable activities), depressed mood, and low energy. Other cognitive symptoms (e.g. pes-
the subject of political and public debate. The simistic thoughts, feelings of guilt, low self-esteem and suicidal ideations) and somatic symp-
“International Journal of Ethics of Science and toms (e.g. sleep and psychomotor disturbances, food-intake and body-weight dysregulation)
Technology Assessment Poiesis & Praxis” is are also present quite often. Unipolar major depression is the leading cause of disability
therefore conceived as an inter-disciplinary fo- worldwide and is associated with a high mortality due to suicide and increases in mortality
rum for reflections on the scientific and techno- in comorbid somatic disorders such as cardiovascular disorders or cancer. Modern medica-
logical future of our civilisation. It aims at in- tion treatments, in conjunction with certain methods of psychotherapy, are effective at alle-
terested researchers from philosophy, natural, viating depressive symptomatology in most patients. However, these treatments do not work
for all affected subjects. A sizable minority of patients does not respond. Indeed, 17–21% of
social and legal sciences, as well as from med- patients suffering from major depression have a poor outcome after two years, and 8–13%
ical disciplines. Moreover, it addresses decision- have a poor outcome even after five years of treatment. Since these patients do not respond
makers in political institutions and in business to any known treatment combination including electroconvulsive therapy, they are referred
to as “treatment resistant”. This underserved population has had little hope of recovering
The contributions collected within this journal from this disease.
are devoted to: (1) Research into the societalconsequences of scientific, technological and Early Promise of Neuromodulatory
leads to novel ideas about targeted neuro- bio-medical advancement; (2) corresponding Treatments
reflections in the sense of technology assess- Indeed, a first approach for intervening in ment and/or ethics of science; (3) discussion of very treatment resistant patients by neuro- the ideas and procedures of ethics of science the brain, many of which may be unrelated surgical means dates back to the origins of and technology assessment; (4) the analysis of neurosurgery itself. Targeted irreversible the relation between these reflective efforts and cused, targeted treatment approaches that destruction of brain tissue – more or less guided by hypotheses on the neurophysiol- The most recent issues of Poiesis & Praxis ogy of the disorders to be treated – was focused on problems of modern “IT and Soci- help treatment-resistant patients. In other used to modulate networks and behaviors.
ety” and on prospects and perils of “Innova- words, whereas existing depression treat- tions in Neuroscience”. New authors and readers are highly welcome to enrich this the shortcomings of the traditional meth- forum of interdisciplinary reflection. Interest- ods. It refers to the delivery of electrical ed parties may visit the corresponding pages of thinking of depression as a dysfunction of currents with adjustable frequency, polari- the academy’s site at www.europaeische- specific brain networks that mediate mood ty, amplitude and pulse-width by a system and reward signals. This conceptualization Europäische Akademie Bad Neuenahr-Ahrweiler cacious treatment. This process will most neuromodulation is adjustable and fully likely be slow, because there is much less reversible; the preoperative situation can public and industry funding than for phar- the research group or at least by an inde- maceutical studies. Nevertheless, DBS has At present, DBS is a common treatment for pendent psychiatrist. Early on, consensus clearly effects on behavior, which is cer- guidelines have to be established coopera- son’s disease (specifically tremor), and es- tively by psychiatrists, neurosurgeons and sential tremor, and is currently also under ethicists, continuously weighing potential with great potential as a research tool.
investigation for use in other indications risks and benefits of the procedure as new with other methods, for instance from neu- treatment refractory obsessive-compulsive Patients with chronic pain, depression and disorder. Recently, the results of DBS close obsessive-compulsive disorder are vulnera- useful to test functional connectivity, neu- to the subgenual cingulate region in six pa- ble groups and therefore require particu- roplasticity, information processing, indi- tients with refractory depression were re- larly careful scrutiny because the long-term rect and direct motor control, as well as as- ported by Mayberg et al. (cf. Neuron safety of neuromodulatory therapies is un- pects of mood control. It affords testing of either general hypotheses of the brain’s this target based on their previous findings DBS in patients with dystonia and Parkin- functioning at different levels or hypothe- that this region is involved in acute stimu- son disease occurs in a situation in which lus-induced sadness, is metabolically over- active in treatment-resistant depression, tributes to the conceptualization of even and that clinical improvement after phar- The clinical significance of these results re- lated with decreases in its metabolic activi- obsessive-compulsive disorder since spon- mains to be determined. But regardless of the outcome of this process, this research might well shed light on some factors es- sential to antidepressant response. We are that do benefit some individuals who have physicians in addition to being researchers; Ethical Issues in this Patient Group
not responded to prior treatments. This is not true of many patients with psychiatric help patients afflicted with a deadly dis- yet published results are very promising, disorders or chronic pain; we therefore be- even the use of reversible neuromodulato- lieve that extra scrutiny in patient selection ry techniques for the putative treatment of edge on the neurobiology of this very dis- depression raises several concerns not or ease? This knowledge might most certainly less associated with other treatments being der both for society and the affected indi- contribute to the development of more fo- researched. Firstly, the need for this new tremely reduced quality of life and total physicians and researchers we should bal- there is a broad range of available treat- hopelessness is a key diagnostic factor of ance the goals of establishing more effec- the disorder. It is understandable that these patients, certainly after a long and treat- searching for ways to improve the quality some patients even with severe and chron- ment resistant course would do anything to of life for patients in our care. These goals with depression are generally considered to some might perceive it. Rather to the con- treatment. Secondly, DBS is associated be able to give informed consent, decisions trary, the concern for the suffering of pa- with severe risks occurring rarely such as about inclusion in a DBS protocol have to tients is the most important driving factor bleeding into the brain, infection related to the implants, or hemiparesis. Thirdly, the steps in information of the patients’ social critical science, to even better treatments in use of neurosurgery for psychiatric disor- ders has a long but somewhat tainted his- tory. Therefore, surgery on the brain – al. can certainly be seen as a proof of the even when fully reversible and adjustable, There is certainly no consensus as of yet principle that reducing depression associ- and even if only applied in extremely des- ated hyperactivity in a certain brain region perate patients suffering from a potentially (cg25) is associated with symptomatic im- deadly mental disorder – requires special might induce antidepressant effects. How- ethical consideration. These reasons neces- ever, this is also the case for many (most) DBS as a new clinical opportunity. Further sitate a careful multidisciplinary and sys- other antidepressant treatments. There are studies should use controlled designs, ex- tematic assessment of treatment refractori- plore different stimulation sites and pa- large parameter space has therefore to be eligibility. The strict adherence to the in- explored in order to find out the most effi- Europäische Akademie Bad Neuenahr-Ahrweiler as worked out in his philosophical habili- Heyen will be responsible for all matters of necessary length of treatment and possible tation, that will be completed soon. Fur- administration and finance. She will also be cessation effects. Following this path, we ther topics will be the plurality of the con- the contact person for all business and legal cepts of risk and the limits and power of matters concerning the corporation, espe- ities for very severe, chronic and treat- cially for the shareholders and sponsors of in addition learn more about the underly- Droste-Franke will coordinate the project Dr. phil. Georg Kamp, M.A.
“Fuel cells and virtual power plants as ele- ments for a sustainable development. Inno- which might ultimately lead to the devel- vation barriers and implementation strate- even more favorable risk-benefit-profile. In the meantime, DBS in the treatment of de-pression will take place within the con- For more information please seewww.europaeische-akademie-aw.de straints of carefully planned clinical trialswith the highest ethical standards possible. Historically, neurosurgical interventions Potentials and Risks of
for psychiatric disorders were radically de- Bundesverdienstkreuz
structive crude interventions, indiscrimi- nately applied, often undertaken with the for the first time on July 24th/25th 2006 in aim to better control difficult patients, nei- Bad Neuenahr Ahrweiler. The project picks up a topic which has already been dealt with ing assessed its effects systematically. The in the now concluded project “Intervening in the Psyche. Novel Possibilities as Social Chal- results from translational research on the lenges”. This project explored various new standard of clinical research in psychiatry among other legal and ethical issues, tackled questions related to the possibility of such in- cation of ethical research guidelines have terventions being used for non-therapeutic changed this perspective completely. Neu- purposes. In doing so, the project group be- rosurgery might have the potential to help came increasingly aware of the diversity and those patients with the severest forms of Berufung
dazzling complexity of the issues raised by an emerging social trend toward utilizing med- ical means for the enhancement of emotional Professor Dr. med. Thomas Schläpfer is Vice Chair
senschaftlichen Beirat des Philosophischen wellbeing and cognitive performance beyond of Psychiatry and Psychotherapy at the Universi- Jahrbuchs (Verlag Karl Alber Freiburg what is considered “normal” or “natural” in tätsklinikum Bonn, he holds a joint appointment atthe Department of Psychiatry at the Johns Hopkins healthy individuals. The clearest indication of this kind of development is given by the European Platform
well-established fact that a growing number Dr. phil. Thorsten Galert has been invit- of people are ready to consume psychophar- ed to participate in the “European Plat- maceutical drugs to achieve mood or cogni- form for Life Sciences, Mind Sciences, and tive enhancement. The two most cited exam- Practical Philosophy
the Humanities”. The aim of this initiative ples for this trend are, first, regarding mood enhancement the Selective Serotonin Reup- Foundation is to establish an interdiscipli- take Inhibitors (most notably “Prozac”), an- tidepressants allegedly permitting people from discussions in the academy’s project who are carrying out research in topics re- without depression to feel “better than well”, groups or in the context of other research lated to the growing academic and societal and second, as regards cognitive enhance- activities as e.g. the doctorate or habilita- ment Methylphenidate (“Ritalin”) which nologies. The first activity of this platform seems not only fit for restraining hyperactive of the academy’s staff the work within this children but apparently also gives a competi- study group is genuine interdisciplinary re- cants scheduled to take place from 11th to tive edge to everyone else who feels in need of search and at the same time for each par- some extra attentive capacity. (For a recent ac- ticipant an internal further training across count of selected ethical questions concerning New Staff Members
cognitive enhancement see the contribution of In the first half of 2006 the study group Cambridge psychologists Professor Barbara Sahakian and Dr. Danielle Turner to the latest “consent” by Dr. med. Felix Thiele, M.Sc., Dr.-Ing. Bert Droste-Franke, Dipl.-Phys.
issue of Poiesis & Praxis (2006) 4/2:81–94.) Europäische Akademie Bad Neuenahr-Ahrweiler The new joint project is funded by the Ger- man Federal Ministry of Education and Re-search (BMBF) as part of an initiative for Margret Engelhard/Friedrich Breyer
“Research into Ethical, Legal and Social As- pects of Biomedicine”. For seamless contin- chen Unterstützung, keine Bestrafung“, in: uation of the former project group’s work its chairman, Professor Dr. jur. Reinhard Deutschlands e.V. Arzt und Krankenhaus. Merkel (Universität Hamburg), and its co- Fachzeitschrift für die Krankenhausärzte ordinator, Dr. phil. Thorsten Galert, also und das Krankenhaus. 79 (8), Lübeck, them, Professor Dr. med. Isabella Heuser,director of the University Hospital for Psy- Carl Friedrich Gethmann
chiatry and Psychotherapy (Charité, Berlin), Manifest Gesundheitssystem, Berlin- accepted to contribute her medical expertise to the project group. Finally, Professor Dr.
med. Bettina Schöne-Seifert, director of the Institute for Ethics, History and Theory of straß, E. Schmidt-Aßmann, G. Stock, J.
Medicine at the Universität Münster and North-Rhine Westfalia, holds the chair of Ethics Council, will devote herself to issues Felix Thiele
Livestock Biotechnology at the Technische of medical ethics pertaining to psychophar- “Predictive medicine and the role of the Universität München. She gained a diploma physician’s power of judgment”, in: A. de scope of the German Ministry’s initiative af- Bouvet, P. Boitte, G. Aiguier (eds.), Ques- fords each of the three partners of the Eu- tions éthiques en médicine prédictive. ropäische Akademie to employ a junior sci- entist to assist them in their research for the project. The first meeting was primarily de- voted to set the agenda for the two-and-a- chusetts Institute of Technology, Massachu- half years of the project’s course (scheduled Carl Friedrich Gethmann
setts, USA. Here she carried out early devel- end: December 2008). Furthermore, Profes- sor Merkel, whose main contribution to the insertional mutagenesis and gene therapy, concluded project “Intervening in the Psy- lungstheoretische Überlegungen zur soge- gene targeting and the production of trans- che” regards issues of mental enhancement, genic models of human genetic disease. Sub- Interdisziplinäre Arbeitsgruppe Human- sequently she joined Colorado State Univer- will be completed by the three junior scien- apeutics in Edinburgh, UK, becoming Assis- Vorstellung des Manifest Gesundheitswe- tant Director of Research in 2001. Her re- Dr. phil. Thorsten Galert, M.A.
sen, Berlin-Brandenburgischen Akademie Phone +49 (0) 2641 firstname.lastname@example.org pharmaceutical proteins in the milk oftransgenic large animals and generation ofxenotransplantation donors. She has devel-oped key technologies for the production oftransgenic livestock, most notably somaticcell nuclear transfer – achieved with the Publisher:
birth of Dolly the sheep – and the first gene Europäische Akademie zur Erforschung von Folgen wissenschaftlich-technischer EntwicklungenBad Neuenahr-Ahrweiler GmbH, Wilhelmstraße 56, D-53474 Bad Neuenahr-Ahrweiler targeted livestock. Her current research fo- cuses on animal stem cells and genome engi- email@example.com, Internet: www.europaeische-akademie-aw.de neering in livestock species for bio-medical Director:
applications and functional genomics.
Professor Dr. phil. Dr. phil. h.c. Carl Friedrich Gethmann (V.i.S.d.P.) Editing:
Katharina Mader, M.A., Phone +49 (0) 26 41 973-313, Fax 973-320,
Professor D.Phil. Angelika Schnieke holds a chair
for Livestock Biotechnology at the Technische Universität München. She is a member of the aca- Warlich Druck Ahrweiler GmbH, Bad Neuenahr-Ahrweiler demy´s project group “Pharming. Genetically ISSN 1432-0150, frequency of publication: 6 –10 times per year, 2.700 copies, Modified Plants and Animals as Future Production reproduction is permitted with reference to the source, please send two voucher copies.
Case Report Coca-Cola and kangaroos Lancet 2004; 364: 1190 Department of Nephrology, In March, 2002, a 44-year-old ostrich farmer fromD W Johnson PhD) Princess outback Australia experienced a sudden onset of muscle Alexandra Hospital, Brisbane, weakness after returning home from an evening of Queensland, Australia shooting kangaroos. He had difﬁculty getting out of