Imaging or Imagining? A Neuroethics Challenge Informed by ...
Imaging or Imagining? A
Neuroethics Challenge Informed
Judy Illes, Stanford University
Eric Racine, Stanford University
From a twenty-ﬁrst century partnership between bioethics and neuroscience, the modern ﬁeld Keywords
of neuroethics is emerging, and technologies enabling functional neuroimaging with unprece- neuroethics
dented sensitivity have brought new ethical, social and legal issues to the forefront. Some neuroimaging
issues, akin to those surrounding modern genetics, raise critical questions regarding predic-
tion of disease, privacy and identity. However, with new and still-evolving insights into our and ethics
neurobiology and previously unquantiﬁable features of profoundly personal behaviors such bioethics
as social attitude, value and moral agency, the difﬁculty of carefully and properly interpreting
the relationship between brain ﬁndings and our own self-concept is unprecedented. Therefore,
while the ethics of genetics provides a legitimate starting point—even a backbone—for tackling Open Peer
ethical issues in neuroimaging, they do not sufﬁce. Drawing on recent neuroimaging ﬁndings Commentaries
and their plausible real-world applications, we argue that interpretation of neuroimaging data
Donald Kennedy, p. 19
is a key epistemological and ethical challenge. This challenge is two-fold. First, at the scientiﬁc
Benjamin S. Wilfond
level, the sheer complexity of neuroscience research poses challenges for integration of knowl- and Vardit Ravitsky, p. 20
edge and meaningful interpretation of data. Second, at the social and cultural level, we ﬁnd that
interpretations of imaging studies are bound by cultural and anthropological frameworks. In and Francoise Baylis, p. 21
particular, the introduction of concepts of self and personhood in neuroimaging illustrates the Paul J. Ford
interaction of interpretation levels and is a major reason why ethical reﬂection on genetics will and Cynthia S. Kubu, p. 23
only partially help settle neuroethical issues. Indeed, ethical interpretation of such ﬁndings will Raymond De Vries, p. 25
necessitate not only traditional bioethical input but also a wider perspective on the construction Jocelyn Downie
of scientiﬁc knowledge. and Michael Hadskis, p. 27
Hubert Doucet, p. 29
Kathinka Evers, p. 31
INTRODUCTION roethics has emerged. While neuroethical discus- Bartha Maria Knoppers, p. 33
sion and debate about psychological states and phys- Chris Buford
What a sensation stethoscopy caused! Soon we will iological processes date back to the ancient philoso- and Fritz Allhoff, p. 34
have reached the point where every barber uses it; phers, advanced capabilities for understanding and Ari Schick, p. 36
when he is shaving you, he will ask: ’Would you monitoring human thought and behavior enabled
care to be stethoscoped, sir?’ Then someone else will by modern neurotechnologies have brought new
invent an instrument for listening to the pulses of the ethical, social and legal issues to the forefront. They
brain. That will make a tremendous stir, until in ﬁfty
draw on and extend anatomo-clinical approaches to
years’ time every barber can do it. Then, when one
has had a haircut and shave and been stethoscoped cerebral localization and functional specialization
(for by now it will be quite common), the barber will that began in the 16th and 17th centuries, after a
ask, ’Perhaps, sir, you would like me to listen to your hiatus of more than two millennia from the days
brain-pulses?’ of Aristotle and Hippocrates (300 and 400 BCE;
—Kierkegaard, 1846 Marshall and Fink 2003). Some issues, akin to
those surrounding modern genetics, raise critical
From a twenty-ﬁrst century partnership be- questions regarding prediction of disease, privacy
tween bioethics and neuroscience, modern neu- and identity. However, with new and still-evolving
The American Journal of Bioethics, 5(2): 5–18, 2005 ajob 5
Copyright c Taylor & Francis, Inc.
ISSN: 1526-5161 print / 1536-0075 online
The American Journal of Bioethics
insights to our neurobiology and previously un- neuroimaging illustrates the interaction of interpre-
quantiﬁable features of profoundly personal behav- tation levels. Addressing the challenge will involve
iors such as social attitude, value and moral agency, creative human imagination and conscious aware-
the difﬁculty of carefully and properly interpret- ness of scientiﬁc and cultural presuppositions.
ing the relationship between brain ﬁndings and our This paper, therefore, explores the evolution of
own self-concept is unprecedented. Ways of tack- functional brain imaging capabilities that have led
ling practical questions in neuroimaging will de- to bold new ﬁndings and claims about behavior in
pend on how we deal with the fundamental one health and disease. We draw on recent neuroimag-
of interpretation—the principal reason that tradi- ing research and their proposed applications. Taking
tional bioethics analysis, as laid out in the ethics of a closer look at how genetics has been analyzed from
genetics, will not sufﬁce as a guide. an ethical standpoint, we compare issues raised in
Consider, for example, the following sampling genetics with issues in functional neuroimaging us-
of article titles appearing in the scientiﬁc literature ing functional magnetic resonance imaging (fMRI)
the past two to three years: “The Good, the Bad as our model. Finally, we discuss interpretation of
and the Anterior Cingulate” (Miller 2002), “Morals neuroimaging data as a key epistemological and eth-
and the Human Brain: A Working Model” (Moll ical challenge, inescapable for neuroethics and in-
et al. 2003), “Strategizing in the Brain” (Camerer tertwined with the history of neuroscience.
2003), “The Medial Frontal Cortex and the Rapid
Processing of Monetary Gains and Losses” (Gehring FUNCTIONAL NEUROIMAGING
and Willoughby 2002) or “The Neural Basis of Eco- From generations of work by neurotechnologically
nomic Decision-Making in the Ultimatum Game” curious and skilled scientists and engineers, pow-
(Sanfey et al. 2003), as well as those appearing in erful functional neuroimaging tools have been in-
popular print media, such as “How the Mind Reads troduced to the modern era. The most prominent
Other Minds” (Zimmer 2003), “Tapping the Mind” tools to date, electroencephalography (EEG), mag-
(Wickelgren 2003), “Why We’re So Nice: We’re netoencephalography (MEG), positron emission to-
Wired to Cooperate” (Angier 2002), and “There’s mography (PET), single photon emission computed
a Sucker Born in Every Medial Prefrontal Cortex” tomography (SPECT) and functional Magnetic Res-
(Thompson 2003). From these, we observe that onance Imaging (fMRI), have provided a continuing
quantitative proﬁles of brain function—“thought stream of information about human behavior.
maps”—once restricted to the domain of medical re- One of the oldest approaches dates back to 1929,
search and clinical neuropsychiatry, may now have when neuropsychiatrist Hans Berger announced the
a natural relevance in our approach to daily life. invention of the electroencephalogram and showed
This trend conceivably introduces possibilities— that the relative signal strength and position of elec-
or at least desires—for using brain maps to assess trical activity generated at the level of the cere-
the truthfulness of statements and memory in law, bral cortex could be measured using placement of
proﬁling prospective employees for professional and electrodes at the scalp (Karbowski 1990). With its
interpersonal skills, evaluating students for learn- exquisite temporal resolution, the stimulus evoked
ing potential in the classroom, selecting investment EEG response “event related potential” (ERP) was
managers to handle our ﬁnancial portfolios, and the ﬁrst tool to unveil fundamental knowledge
even choosing lifetime partners based on compati- about the working of the human brain in near
ble brain proﬁles for personality, interests and de- real time. Over time, other imaging modalities
sires. Further, these trends bring to the foreground have come to achieve this goal by capitalizing on
what would appear to be a strict epistemological brain signals such as extracranial electromagnetic
challenge at the core of neuroethics—proper inter- activity (MEG), metabolic activity and blood ﬂow
pretation of neuroimaging data. The challenge will (PET and SPECT), and regional blood oxygenation
prove to be two-fold. First, at the scientiﬁc level, (fMRI) that yield different and complex measure-
the sheer complexity of neuroscience research poses ments of functional activity (for a very readable
challenges for integration of knowledge and mean- anthropologic perspective on PET speciﬁcally, see
ingful interpretation of data. Second, at the social Dumit 2004). By and large, all utilize comparison
and cultural level, we ﬁnd that social interpreta- or subtraction methods between two controlled con-
tions of imaging studies are bound by cultural and ditions, heavy statistical processing, and computer
anthropological frameworks. In particular, the in- intensive data reconstructions to produce the col-
troduction of concepts of self and personhood in orful maps with which we have become familiar.
6 ajob March/April 2005, Volume 5, Number 2
Imaging or Imagining?
Figure 1. Experimental (“B” state) images are subtracted from control (“A” state) images to achieve regional
activation maps with fMRI. (Courtesy of Gary H. Glover, Lucas MRS/MRI Center, Stanford University)
All have roots in the diagnosis and intervention of Figure 1. The surplus of oxygenated blood recruited
the wide range of psychiatric and neurological dis- to relatively active brain regions produces the effects
eases known to us, including head trauma, demen- measured by MR.
tia, mood disorders, stroke, cancer, seizures, and the
impact of drug abuse, to mention but a few. Applications of Functional Neuroimaging
The different techniques each have relative ad- in Clinical Medicine, Cognitive Science and Law
vantages and disadvantages; these are summarized Beyond the use of fMRI in mapping of salient corti-
brieﬂy in Table 1 to provide reference for this discus- cal areas prior to surgical intervention for epilepsy,
sion. Given their technical trade-offs, fMRI stands tumors or arteriovenous malformations, other ac-
out as likely to have the greatest enduring im- tive efforts to make the technology relevant in the
pact on our society outside the realm of academia clinical setting have focused on Alzheimer’s Disease
and medicine. It is the widespread availability of (AD), mental illness in adults and pediatric pathol-
MR scanners today and the noninvasiveness of the ogy such as attention deﬁcit hyperactivity disorder
imaging approach enabled by MR have set fMRI (ADHD; Illes and Kirschen 2003). Applications of
apart from other neuroimaging tools and made it fetal MRI have also shown great promise in provid-
a model for neuroethical discussions. The activa- ing better diagnosis of structural central nervous
tion maps produced by fMRI reﬂect indirect ef- system anomalies, and functional studies of fetal
fects of neural activity on local blood ﬂow under brain blood ﬂow are not lagging far behind. At the
constrained experimental conditions. Like PET and opposite end of the life spectrum, ﬁrst approaches
SPECT paradigms, a typical fMRI experiment uti- using fMRI to determine levels of consciousness in
lizes a stimulus designed for acquiring the relative patients in minimally conscious or vegetative states
difference in brain activity between an experimen- have also been attempted (e.g. Schiff et al. 2005)
tal and a control (baseline) task, as illustrated in (Giacino 2003).
March/April 2005, Volume 5, Number 2 ajob 7
Table 1. Characteristics and Trade-offs of Major Functional Neuroimaging Technologies
Measurement Technology Strengths Limitations Notes
EEG Electrical activity measured Electro-encephalogram; 8 to Noninvasive, well-tolerated, low cost, Limited spatial resolution compared Tens of thousands of
at scalp. >200 scalp electrodes. sub-second temporal resolution. to other techniques. EEG/ERP ﬁndings
reported in the literature.
MEG Magnetic ﬁelds measured at Superconducting quantum Noninvasive, well-tolerated, good Cost, extremely limited market and
scalp, computed from interference device temporal resolution. availability.
source-localized electric (SQUID); ∼80–150 sensors
current data. surrounding the head.
PET Regional absorption of Ringed-shaped PET scanner; Highly evolved for staging of cancers, Requires injection or inhalation of
radioactive contrast several hundred radiation measuring cognition function and contrast agent such as glucose or
agents yielding measures detectors surrounding the evolving to a reimbursable imaging oxygen; lag time of up to 30
of metabolic activity and head. tool for predicting disease involving minutes between stimulation and
blood ﬂow. neurocognition such as Alzheimer’s data acquisition, limited
Disease. availability (fewer than 100 PET
scanners exist in US today) given
short half-life of isotopes and few
locations with cyclotrons to
produce them; cost.
SPECT Like PET, another nuclear Multidetector or rotating Documented uses mapping psychiatric Requires injection of contrast agent Currently available in two
medicine technique that gamma camera systems. and neurological disease including through intravenous line; cost. states (CA and CO) for
relies on regional Data can be reconstructed at head trauma, dementia, atypical or purchase without
absorption of radioactive any angle, including the unresponsive mood disorders, strokes, physician referral;
contrast to yield axial, coronal and sagittal seizures, the impact of drug abuse on emphasis is on ADHD and
measures of metabolic planes, or at the same angle brain function, and atypical or Alzheimer’s Disease
activity and blood ﬂow. of imaging obtained with unresponsive aggressive behavior. (approx. out-of-pocket
CT or MRI, to facilitate cost: $3,000 per study).
fMRI Surplus of oxygenated MRI scanner at 1 Tesla to 7 Noninvasive, study repeatability, no Cost of equipment and physics Rapid proliferation of
blood recruited to Tesla and higher; 1.5T most known risks. New applications of MR expertise to run and maintain research studies using
regionally activated common because of its wide in imaging diffusion tensor maps systems. fMRI alone or in
brain. clinical availability. (DTI)—namely, the microstructural combination with other
orientation of white matter ﬁbers—has modalities, growing from
recently been shown to have good 15 in 1991 (13 journals) to
correlation with IQ, reading ability, 2,224 papers in 2003 (335
personality and other trait measures journals), representing an
(Klingberg et al. 2000). average increase of 56%
Note: Combined modality systems such as EEG and fMRI are becoming increasingly common. PET and SPECT are forerunners to frontier technology in molecular imaging.
Imaging or Imagining?
Over the past ten years of fMRI develop- poor functioning in the prefrontal cortex, a locus of
ment and expanding boundaries of cognitive neuro- impulse control (Raine et al. 1994). In some cases,
science, the innovation has been applied to gain new PET images have been used to argue that a defen-
non-health related knowledge about human moti- dant was biologically predisposed to committing a
vation, reasoning, and social attitudes. In a compre- crime and, therefore, should be spared a conviction
hensive literature review, we demonstrated a steady or death sentence. In at least one court case (People
expansion of fMRI studies, alone or in combina- v. Jones) a homicide conviction was reversed because
tion with other imaging modalities, with evident the state failed to provide brain scans.1
social and policy implications, including studies of In a relatively new application of EEG, EEG-
lying and deception, human cooperation and com- derived “brain ﬁngerprinting” has been promoted
petition, brain differences in violent people, genetic as a tool for determining whether an individual
inﬂuences, and variability in patterns of brain de- is in possession of certain knowledge of a crime
velopment (Illes et al. 2003). In one intriguing but (Farwell and Smith 2001). It is the possession—
unpublished study, Beauregard et al. (reviewed in or lack of possession—of the relevant facts about a
Curran 2003) used a combination of EEG, fMRI crime that brain ﬁngerprinting attempts to quantify
and PET to probe neural underpinnings of religious through measures of brain-wave responses to rele-
experience (Curran 2003). They are focusing on the vant words or pictures presented at rapid rates on a
phenomenon known as unio mystica, a joyous sense of computer screen. When the brain recognizes signif-
union with God reportedly experienced by a group icant information—such as crime scene details—it
of cloistered Carmelite nuns in Montreal, Canada. responds with a “memory and encoding related mul-
Discussion of the potential meaning and practical tifaceted electroencephalographic response.” Un-
uses of such deeply personal neuroproﬁles is ripe for like polygraph testing that measures an individual’s
bioethical consideration. fear of getting caught in a lie by tracking relevant
Outside the arenas of medicine and cognitive physiological markers, brain ﬁngerprinting ostensi-
science, the legal arena offers an obvious venue for bly measures brain waves emitted when information
attempting to translate neuroimaging into mean- stored in the brain is recognized.2
ingful, real-world use. As Hank Greely (2002, 5) New applications of fMRI that bridge cognitive
wrote: science and law also have the potential to change
approaches to truth veriﬁcation and lie detection.
Neuroscience may provide answers to some of the Langleben et al. (2001), for example, used fMRI
‘oldest philosophical questions, shedding light, for to study neural patterns associated with deception.
example, on existence limits, and meaning of free In their landmark experiment, volunteers were in-
will.’ It may also provide new ways to distinguish
structed to either truthfully or falsely conﬁrm or
truth from lies or real memories from false ones. This
ability to predict behavior with the help of neuro-
science could have important consequences for the 1. In a 1992 New York murder case, People v. Weinstein,
judicial system as well as for society as a whole. Weinstein was accused of strangling his wife to death and
throwing her body from a twelfth-ﬂoor apartment. We-
Greely provides an extensive review of the legal is- instein’s functional PET scans and structural MRI images
sues in his chapter “Prediction, Litigation, Privacy, revealed an arachnoid cyst, and the evidence was admit-
and Property: Some Possible Legal and Social Im- ted in court for the purpose of establishing an insanity
defense. The ruling was made despite evidence that such
plications of Advances in Neuroscience.” (Greely pathology has no known link to criminal behavior. The
2004). A few cases suitable to elucidating where PET scan depicted the juxtaposition of a black lesion (the
ethical models for brain imaging may intersect with cyst) on the red and green colored areas of ‘normal’ brain
or diverge from genetics are explored here. activity, and was considered so profound as to prove to the
Looking back to 1985, when a Supreme Court court that Weinstein’s brain was not functioning within
normal parameters. The prosecution in this case accepted
holding in Ake v. Oklahoma imposed a constitutional a manslaughter plea.
requirement for states to provide psychiatric assis- 2. Brain ﬁngerprinting played a signiﬁcant role in the case
tance in a criminal defense when the question of of Terry Harrington, for example, whose murder convic-
sanity is raised, criminal defendants began to argue tion was reversed and a new trial ordered after he spent
that ‘psychiatric assistance’ should include a com- 22 years in prison (State of Iowa v. Terry Harrington). The
case dates back to 1977, when Harrington, who was 17
plete neurological evaluation including scans like years old at the time, was convicted of murdering a re-
PET or MRI. PET studies have shown that com- tired police ofﬁcer. When, in 2000, Harrington under-
mitted murderers, for example, as a group, have went ﬁngerprinting, his brain did not emit the expected
March/April 2005, Volume 5, Number 2 ajob 9
The American Journal of Bioethics
deny having a playing card in their possession. on some major ethical, legal and social (ELSI) vari-
When subjects gave truthful answers, the fMRI ables, this section examines the extent to which the
showed increased activity in visual and motor cor- ethics of genomics can serve as a model for ethical
tex. When they were deliberately deceptive, addi- analysis of neuroimaging.
tional activations were measured in areas including
the anterior cingulate cortex to which monitoring of Discrimination, Stigma
errors and attention has been attributed. Langleben Given the growing recognition that health infor-
et al. concluded that “essentially, it took more men- mation is not entirely private, Clayton (2003) and
tal energy to lie than to tell the truth” (Evans others (e.g., Rothenberg and Terry 2002) have sug-
2002). These results are consistent with those of gested that the most common fear about genetic in-
Moll et al. (2003) and Heilman (1997) that im- formation is its potential use in justifying denial of
plicate the temporo-polar cortex, insula, precuneus access to health insurance, employment, education
and their connections in an extended neural cir- and even ﬁnancial loans to people with particular ge-
cuit that attributes conscious emotions and feelings, netic characteristics or diagnoses. While these issues
especially those with a social context, to percep- may not be the immediate ones for neuroimaging,
tions and ideations (see also Aldolphs et al. 1995; as we have seen, little stands in the way for sim-
Damasio 1994; LeDoux 2003). In the future, there- ilar concerns about neuroproﬁling with functional
fore, we may not only be able to discern whether an imaging to arise even as neuroimaging techniques
individual is being deceptive, but also whether the continue to mature. While neuroscientists tease out
deception was premeditated or not.3 artifacts masquerading as neural effects and develop
PATHWAYS FROM GENETICS TO analytic methods that provide more intuitive ways
NEUROIMAGING SCIENCE of interpreting the data than possible today, there
already exists a healthy regard for the novelty and
Ellen Wright Clayton (2003) provides a compre- breadth of information that neuroimaging can de-
hensive review of the impact that advancements in liver about human health, behavior and cognitive
genetics and molecular biology have had on soci- ﬁtness. How will such technology be used advanta-
ety, and she argues for genomics as a complex phe- geously to beneﬁt people and society? Could it be
nomenon that presents speciﬁc challenges for clini- used harmfully for ill-intentioned purposes? Will
cians and patients alike. Neuroscience is no less eth- Canli’s paradigms for imaging personality become
ically complex, and neuroscientists, like geneticists adopted for triaging team players or weak decision-
and nuclear physicists even before them, are increas- makers in the workplace (Canli and Amin 2002) or,
ingly gaining awareness about the potential impli- in this post-Columbine era, at the door of our high
cations of their research at the bench, in medicine, schools to triage out students with a predisposition
and in the public domain (Mariani 2003).4 Drawing to unruly or violent behavior? Perhaps screening for
good humor would be more acceptable (Canli et al.
electroencephalographic patterns in response to critical 2002; Mobbs et al. 2003).
details of the murder. The results were interpreted to It will be the moral obligation of bioethicists
suggest that he was not present at the murder site, a
conclusion corroborated by the fact that his brain did emit
and neuroscientists alike to think proactively about
the requisite patterns in response to details of the event the impact that such effects might have on peo-
used as his alibi in the case. When confronted with the ple, from the point of view both of beneﬁts such
brain ﬁngerprinting evidence, the original prosecution as self-knowledge (Weir et al. 1994) and personal
witness recanted his testimony and admitted that he had choice, as well as risks, especially for children and
lied during the original trial, falsely accusing Harrington
to avoid being prosecuted himself.
adolescents at critical stages in their personal and
3. In another fMRI experiment related to deception and educational development (Savelscu 2001). By what
more broadly to lying, Schacter et al. (1998) demon- means will anyone resist coercive uses of such tech-
strated the potential to discern false from truthful mem- nology if employment or educational opportunity
ory. In an even more recent study, Anderson et al. (2004) are at stake? If the paradigms of Golby et al. (2001),
showed areas of neural activation in the dorsolateral pre-
frontal cortex associated with the active suppression of
Phelps et al. (2003), or Richeson et al. (2003) for
memory. studying race and social attitudes could be adopted
4. Even in these early stages, some ire about who is
conducting what kind of research and with what mo-
tivation has already surfaced, especially with respect to wards and not deliver either scholarly or medical beneﬁt
research that would seem only to yield ﬁnancial re- (Gardner 2003).
10 ajob March/April 2005, Volume 5, Number 2
Imaging or Imagining?
for determining eligibility to become a police of- Genetic versus Neuro Determinism
ﬁcer, a school principal, or even a national leader, Despite its probabilistic nature, genetic informa-
would this be a legitimate allocation of public tion tends to be viewed as a deﬁnitive form of health
funds? Much mischief beyond discrimination and data. Individuals feel a sense of inevitability with
stigma may be created by over-interpretation of any regard to their genes, Clayton (2003) argues, as
such results (see also Editorial, “Scanning the So- well as a sense of genetic determinism. Such deter-
cial Brain,” Nature Neuroscience, November 2003, minism, or genomic essentialism (Mauron 2003),
1239). has become popular in our culture especially in the
way that results of behavioral genetics studies are
Privacy of Human Thought
communicated to the public. We have read reports
Functional neuroimaging poses pivotal challenges about genes for violence, homosexuality, alcoholism
to thought privacy. Should thought information and even one for language. The essentialist stance
have similar privacy status as genetic information? is strengthened by the fact we have a tendency to
Probably not less, but perhaps more. No doubt, in- believe that we are our brains. However, longstand-
creased information about the neurobiology of how ing studies of developmental brain plasticity and
we think, and potentially why we think what we new activation studies of reorganization after in-
think, is likely to cause signiﬁcant ethical dilem- jury have amply demonstrated that any such reduc-
mas for clinicians and researchers, especially as mea- tionist view of complex phenotypes is incomplete
sured thought patterns may vary as much with the without consideration of intervening external and
hemodynamic properties of the relevant vascula- cultural factors (Ward and Frackowiak 2004). Some
ture (D’Esposito et al. 2003) as with gender and have argued that the biological sciences, which deal
day-to-day variations in mood and attention (Gur with open systems, are improperly ﬁt for universal
et al. 1975). Moreover, they are highly subject to and deterministic laws, as are physics and chemistry
variability in the culture and values of the people (Mayr 1998). Arguments that make neuroscience
interpreting them (Beaulieu 2002; Dumit 2004). deterministic could well be ﬂawed conceptually and
Watson (as cited in Mauron 2003, 245) has stated empirically (Racine 2005). However, given the ten-
that the human genome is, at least in part, “what dency to oversimplify complex genetic and brain
makes us.” The “brainome” (Kennedy 2003), then, data, discussion of meaning and practical use is a
touches more upon who we fundamentally “are”— clear imperative.
gnarly territory, at best.
With a small leap of faith for real-world validity,
the way in which these studies are edging toward Prediction of Disease, Public Health
biologic measurements of personhood is illustrated, Countless medical examples exist of symptomatic
for example, in a now-landmark trolley car study by individuals who, with an inherited genetic defect
Greene et al. (2001; see also Greene 2003). In this for a given disorder, must carefully monitor their
moral reasoning experiment, subjects were scanned daily activities to ensure their own health and safety
while they made decisions about scenarios in which and that of others. But what of the asymptomatic in-
they could, for example, choose to save the lives of dividual who learns from a functional neuroimage
ﬁve people on a runaway trolley car by pulling a of a predisposition to a disease of the central ner-
switch to send it on an adjacent track where one vous system that ultimately affects cognitive per-
person stands (and who would not survive), or to formance and lifelong independence? What are the
push one of the people off the trolley and on to the implications for third parties, as in the case of neu-
track, thereby blocking the movement of the trol- rogenetic disorders, for which functional patterns
ley and saving the remainder of the group. Other may surface as sensitive predictors of disease? What
studies have required research participants to re- is the new role of physicians in the entrepreneurial
solve statements of moral content (e.g., “The judge world of self-referred imaging services?
condemned the innocent man” or “The elderly are Work on imaging-based diagnosis holds enor-
useless”) versus neutral content (“The painter used mous promise for providing new, quantitative evi-
his hand as a paintbrush”; Moll et al. 2002). All dence for otherwise qualitative diagnoses based on
such studies touch upon human thought processes clinical ﬁndings, however it also raises compelling
that push the envelope of cognitive neuroscience questions about what cautions are needed as patients
into a domain of signiﬁcant social concern in which yearn for earlier and earlier diagnosis about diseases
privacy is a vital ingredient. for which cures or even treatments do not yet exist.
March/April 2005, Volume 5, Number 2 ajob 11
The American Journal of Bioethics
Will such data provide welcome new information where, when, or how a crime occurred, nor individ-
or impose new burdens on families, physicians and ual guilt (Committee to Review the Scientiﬁc Evi-
allied health care professionals? Who will have ac- dence on the Polygraph 2003), the constant stream
cess to this technology? How will physicians and of innovative scientiﬁc approaches is aimed at de-
patients incorporate these new types of data into riving biologic correlates for behaviors committed
their reasoning about treatment, compliance and in the past (Illes, 2005) is unrelenting. As we seek
life planning? Access to advanced technologies by to understand responsibility of others through their
the privileged only, whether for diagnosis, medi- biology, it is incumbent upon us to contemplate, yet
cal intervention or for a competitive neurocognitive again, our own responsibilities in interpreting such
edge, will only further upset an already delicate and information, and in protecting access and appropri-
hardly acceptable status quo. ate use.
Conﬁdentiality and Responsibility
We are in an era of neuroinformatics in which shar-
ing of genetic, brain, and other data is encouraged. In Table 2 we summarize areas where ELSI in ge-
In some cases of large federally sponsored research, netics converge with and diverge from neuroimag-
brain data sharing is even required (Koslow and ing. These are the crossroads at which we can begin
Hyman 2000). With only partial brain informa- to transition to our thinking about the ethics of
tion is now needed to identify research partici- making brain maps from our experience with ge-
pants, and new imaging genomics studies (Hariri netics. As the discussion above and this table both
and Weinberger 2003) coupling genetic informa- show, similarities are striking and span the domains
tion with brain mapping (“genotyped cognition”; of both research and clinical ethics. They include
Hammann and Canli 2004), major new uncertain- profound practical beneﬁts, including new knowl-
ties exist about the safety and conﬁdentiality of edge about the human condition and knowledge
data stored in cyberspace. Other issues concern the that informs self-determination and life planning.
protection of human subjects, including conﬁden- They include negatives, such as the potential for
tiality and responsibility related to incidental ﬁnd- personal and legal discrimination, inequities of ac-
ings. What if pathology is discovered unexpect- cess, risks to conﬁdentiality, inaccuracies inherent
edly in a shared data set? With whom does the to predictive testing of any nature and associated
burden of disclosure and care lie—the primary or anxiety (Michie et al. 2002), and commercial use
secondary laboratory? Beyond the laboratory, how (Merz et al. 2002). Pressing issues unique to genet-
shall commercial use of freely shared brain imaging ics but not to neuroimaging are not apparent, but
data in the for-proﬁt sector be deﬁned? No doubt, the reverse is noteworthy in as much as the wide
countless other examples exist in research beyond range of technical and subjective factors, including
these few. paradigmatic, physiologic and investigator biases in
As we have seen, our concept of legal respon- research play into the interpretation of results and
sibility may also be changed by neuroimaging. In the global potential for biologizing human experi-
the United Kingdom, cautions about the use of neu- ence that reaches far beyond any previous window
roimages such as PET in the courtroom have already on individual traits.
been expressed. In 2002, for example, at a debate
entitled “Neuroscience and the Law” hosted by the INTERPRETATION AS A KEY NEUROETHICAL
Royal Institution of Great Britain, forensic psychia- CHALLENGE
trist and criminal barrister Eastman argued that the The idea that the genome is the “secular equiva-
neuroimaging science is still too imprecise to make lent of the soul” has been legitimately criticized
“an unequivocal connection between brain struc- (Mauron 2001). New to neuroethics will be the need
ture and behavior.” “Even if . . . psychopaths have to tackle responsibly—with the inevitable and om-
physically different brains from other people, does nipresent working hypothesis (or the “astonishing
it mean anything? Does an abnormal brain auto- hypothesis” to quote Crick 1997)—that the mind
matically mean abnormal behavior? Does it mean a is the brain. Responsible and careful interpretation
loss of control sufﬁcient to impact on legal respon- of data will therefore become a crucial issue as we
sibility? Do you abolish free will on the basis of wrestle to untangle what we image from what we
an odd brain scan?” Even while neuroimaging can- imagine. Here, genetics as a model is limited and
not establish moral culpability (Kulynych 1997) of bioethicists will have the greatest role in bringing
12 ajob March/April 2005, Volume 5, Number 2
Imaging or Imagining?
Table 2. Comparison of Ethical, Legal and Social Issues in Genetics and Functional Neuroimaging
ELSI variables Gene hunting, Gene testing Functional neuroimaging
Risk of discrimination, stigma, Yes Not at present, but growing concern
coercion exists for the evolution of the
technology and expanding use.
Risk to privacy Yes Yes
Distributive justice Yes Yes, once the technology moves into
mainstream clinical medicine.
Diagnostic uses Yes Emerging
Prediction Yes Emerging
Commercial use Yes Emerging; some limited availability
already exists in the
Paradigmatic variables: Results Potentially but not considered a Highly signiﬁcant given variability in
subject to variability in test used signiﬁcant risk. equipment, hypothesis-testing,
stimulus design and approaches to
Physiologic variables: Results No Highly signiﬁcant given ﬂuctuations,
subject to physiologic and for example, in blood ﬂow, mood,
day-to-day variations. and gender-related physiology.
Investigator variables: Results No, but standards for testing are not Highly signiﬁcant, especially when
subject to variability of widespread. interpretation of data interacts with
interpretation. individual social values and culture.
Biologization of personal thought. Possibly in mental illness and Highly signiﬁcant as complex
neuro-degenerative disease. thought becomes quantiﬁed and
visualized on brain maps.
critical thinking to the ﬁeld. Fundamentally, the of standards of practice in the laboratory (in fact,
challenge is two-fold as proper ethical interpreta- innovation and creativity still deﬁne the state-of-
tion is a crucial concern at both the scientiﬁc and the-art in neuroimaging today) and the medicole-
the social level. gal setting creates another layer of complexity for
While fMRI today may surpass other neu- drawing conclusions about behavior, responsibility
roimaging techniques in its use for understanding and cognitive well-being (Kulynych 1997; Nelkin
human behaviors that may have practical relevance, and Tancredi 1989) that will need to be penetrated
we are witnessing a dynamic stream of new applica- with appropriately responsive ethical approaches.
tions and new technical possibilities. Like genetic With dynamic images in hand, we may forget the
testing, models for minimizing harm that may re- epistemological limits of how the images were pro-
sult from false positives and inappropriate attribu- duced, including variability in research designs, sta-
tions of cause-and-effect to otherwise correlative re- tistical treatment of the data, and resolution. It is
sults are critical. Apart from genetic testing, brain worth recalling that, in the past, various models
maps can be readily portrayed as iconic proof of of the brain have been proposed by great minds
pathology to people at any level of literacy. Yet, only to be seen later as mere imagination of the
as we have seen, the brain image represents unpar- brain’s real functioning. Descartes used pneumatics
alleled complexity—from the specialized medical as a paradigm to explain how the “animal spirits”
equipment needed to acquire a scan, to the array of were produced by the ﬂow of blood from the heart
parameters used to elicit activations and the statisti- to the brain (Changeux 1983). Later on, the emi-
cal thresholds set to draw out meaningful patterns, nent anatomist Franz Joseph Gall proposed phrenol-
to the expertise required for the objective interpreta- ogy to the courts for establishing facts and choos-
tion of the maps themselves. Moreover, an absence ing appropriate sentences for convicted criminals
March/April 2005, Volume 5, Number 2 ajob 13
The American Journal of Bioethics
(Lanteri-Laura 1996). In the twentieth century, Mo- “Humans are forever prone to make premature and
niz’s psychosurgery procedures certainly left behind presumptuous claims of new knowledge. . . . One
an “unhappy legacy” (Gostin 1980). may think that brain imagery will reveal myster-
Today, some scientists and philosophers urge ies of the human mind. But it may only help us
that we adopt the computer metaphor, neural net- gradually comprehend the organic, chemical and
works or other models to understand brain function. physiological features of the brain rather than pro-
However different and in some sense far apart, these vide the keys to unlock the secrets of human be-
examples highlight cautions needed in the interpre- havior and motivation.” Whatever the outcomes of
tation of brain ﬁndings and their intended applica- imaging turn out to be, they will depend on sci-
tions. In an issue of the journal Brain and Cognition entiﬁc as well as cultural scrutiny of neuroimaging
that represented a pioneering venture into ethical research.
issues in neuroimaging (Illes 2002), the commu- In a study where neuroscientists have teamed-
nity of authors who contributed to it already then up with Buddhist monks to understand the mind
cited cautions of interpretation as a common con- and test for insights gained by meditation (Global
cern. These cautions have been reiterated by oth- News Wire 2003), culturally–laden concepts such
ers (e.g., Gore et al. 2003), and alone justify the as ‘person,’ and ‘emotions’ are being questioned by
increasing attention to frontier neurotechnologies, imaging. Some argue that consciousness and spiri-
their capabilities and limitations, and new ethical tuality could be changed by such ﬁndings on the
approaches for thinking about them (see also Blank, brain. Therefore not only does culture penetrate
1999). neuroimaging; neuroimaging is increasingly pen-
When links are made between neuroimaging etrating non-scientiﬁc culture. This is why neu-
ﬁndings and our self-concepts in particular, it is roethics needs to consider not only ethics of neu-
even clearer that the ethics of genetics can only roscience but also a neuroscience of ethics (Roskies
partially help settle ethical issues. Genetics and 2002) and, we may add, reﬂection on their scientiﬁc
genomics have provided fertile ground for many and cultural implications.
ethical reﬂections on human nature, but the rela- Regardless of the functional neuroimaging tech-
tionship between the brain and the self is far more nology du jour, we are left with lingering inter-
direct than the link between genes and personal pretation and other questions that any new ethical
identity (Mauron 2003). The locus for integrating approach for brain imaging will have to address.
behavior resides in the brain, even if discrete features Time, scholarly dedication and collaboration across
are determined by our genes. Whether neurotech- the vested disciplines will help resolve them. Some
nology measures that behavior through imaging, of these questions, which will inevitably raise the
or manipulates it through implants of neural tissue bar and challenges of interpretation are:
or devices, it will fundamentally alter the dynamic
between personal identity, responsibility and free r Revisiting a classic dichotomy in the conduct of
will in ways that genetics never has. Indeed, neu- research, is there neuroimaging research that we
rotechnologies as a whole are challenging our sense can do (or will be able to do) but ought not to?
of personhood and providing new tools to society If we were to accept that the biology of social
for judging it (Wolpe 2002). processes studied within the constraints of the
Interpretation of neuroimaging studies are not laboratory translates seamlessly to real-world va-
only bound by scientiﬁc frameworks, but also cul- lidity, should the contents of ours minds even be
tural and anthropological ones. Consider concepts studied this way (Foster et al. 2003)? Who should
such as “moral emotions” that are based on assump- decide and according to what scientiﬁc and cul-
tions that some emotions are moral and others not. tural parameters?
They illustrate the cultural aspect of the interpre- r What are the trade-offs between cautious research
tation challenge, which is based on the fact that the with public oversight versus the potential for
self is deﬁned in diverse ways. For example, central over-regulation in a reaction to adverse or reck-
to Buddhism is the Doctrine of No-Soul, whereas in less events? Many lessons may be learned from
Hinduism, the self is a religious and metaphysical genetics, but “reckless” will surely take on new
concept (Morris 1994). Even within Western tra- meaning in discussions about the neurobiology of
ditions, that may appear to be monolithic, various moral reasoning and social behavior.
beliefs have served as “sources of the self” (Taylor r How can the reductionist approach of neuroimag-
1989). As Winslade and Rockwell (2002) wrote, ing to human behavior be made compatible and
14 ajob March/April 2005, Volume 5, Number 2
Imaging or Imagining?
complementary to approaches represented by phi- disease. Recent neuroimaging ﬁndings and their
losophy, sociology and anthropology? How will proposed applications show that a great number
applications based upon this approach interact of new ethical issues will be raised. ELSI variables
with wider cultural perspectives on the self? have given us a invaluable starting point, but, neu-
r Will the large investment in neuroimaging be roethics will need to address issues of data interpre-
justiﬁed by new knowledge? Are there some forms tation in great depth both at the scientiﬁc and the
of funding that should be eschewed because they cultural level. Neuroimaging illustrates this double
may lead to methods for thought control or per- challenge remarkably since imaging technologies
sonal ﬁnancial gain? and methodologies are grounded in scientiﬁc as-
r What new ethical challenges will neurotechnolo- sumptions. Meanwhile, imaging is an area where in-
gies bring us in the future? What will the porta- vestigation of social behavior and selfhood is rapidly
bility of near infra-red optical imaging offer? Shall increasing and becoming a legitimate endeavor. In-
transcranial magnetic stimulation be transferred deed, at the heart of imaging is an effort to make
from the medical arena for treating depression sense of an image in need of interpretation. Right
to the open market for boosting or ﬁne-tuning along side with the new concept of “imaging neu-
cognition like caffeine or other over-the-counter roethics” others like “neuromarketing,” “neuroeco-
stimulants? With advances in reporter probes nomics,” “neuroenablement” (Lynch 2004), “neu-
(Kim 2003), what ethical approaches will be rotheology” and even “neurocorrection” (Farah et al.
needed for managing new information and thera- 2004) have been spawned. All raise concerns about
pies brought forward from the coupling of molec- scientiﬁcally-warranted and culturally-sensitive in-
ular imaging, targeted either in the central ner- terpretation an application.
vous system or elsewhere, and gene therapy trials? With the existence of many views about mind
and brain, neuroethics will have to foster discussions
The answers to these questions will surely not among neuroscientists whose methods may vary and
be binary. As in the past, they will depend funda- interpretation of results differ. These discussions
mentally on individuals involved and the context will have extend to include meaningful dialogue
in which they are confronted. Fresh thinking, espe- with scholars in the humanities about concepts like
cially about the relationship between the self and morality, moral judgments and moral emotions—
the brain, will have to be elaborated for these new concepts in need of critical appraisal before we can
types of brain data as the layers of complexity of seriously investigate their neural correlates. Open
interpretation and overall stakes are arguably far dialogue with the public is no less necessary given
greater than ever before. Commenting on Aldous that different cultural and religious perspectives
Huvley’s Brave New World (1932) written approxi- subject ﬁndings to different interpretations and eth-
mately 100 years after Soren Kierkegaard’s foresight ical boundaries. Responsible dissemination of infor-
on brain pulses, Pontecorvo wrote: mation through the media and public education are
also essential in closing the gap between scientists
The ethical issues raised by . . . feats of human engi-
and concerned citizens, especially as the complexity
neering are qualitatively no different from those we
shall have to face in the future. The difference will be and abstractness of results increase.
quantitative: in scale and rate. Even so, the individ- Interpretation necessitates creative human
ual steps may still go on being so small that none of imagination and conscious awareness of scientiﬁc
them singly will bring those issues forcibly to light: and cultural presuppositions. Hence, the new gen-
but the sum total is likely to be tremendous . . . ” (as eration of neuroethicists must be committed to
cited in Stevens, 2000; pp. 81–82). openly examining the epistemological limits of im-
agery (Racine and Illes 2004), interdisciplinary ap-
Pontecorvo was partly right: There is no doubt praisal, and public perspectives on these issues.
that the sum total is tremendous. He could never Bioethicists will continue to bring ethical knowl-
have predicted, however, the extent to which chang- edge to the discussion and identify and clarify moral
ing qualities would parallel changing quantities. quandaries; bioethicists however, will also have to
work as facilitators of a broader dialogue where
ADDRESSING THE CHALLENGE different perspectives can meet and contribute to
This paper explored the evolution of functional a deeper understanding of the issues. Therefore,
brain imaging capabilities that have led to bold new while in the past technology and ethics may have
ﬁndings and claims about behavior in health and leapfrogged each other, in this new era, bioethicists
March/April 2005, Volume 5, Number 2 ajob 15
The American Journal of Bioethics
and neuroscientists will be well served by working Curran, P. Soul search: Emotions, spirituality and tran-
gracefully together to understand the power of a vi- scendence: Scientist gains notoriefy for work with nuns.
sual image and the impact it can have on people and The Montreal Gazette. Montreal. October 19: A14.
collectively on society. Damasio, A. R. 1994. Descartes’ error. Netcong, NJ:
Penguin Putnam Pubs.
DISCLOSURES D’Esposito, M., L. Y. Deouell, and A. Gazzaley. 2003. Al-
Supported by The Greenwall Foundation, terations in the BOLD fMRI signal with ageing and dis-
NIH/NINDS RO1 #NS045831 and the Social ease: A challenge for neuroimaging. Nature Reviews
Sciences and Humanities Research Council of
Canada # 756-2004-0434. Dumit, J. 2004. Picturing personhood: Brain scan and
biomedical identity. Princeton, NJ, Princeton Univer-
ACKNOWLEDGMENTS sity Press.
Editorial. 2003. Scanning the social brain. Nature Neu-
We are indebted to Dr. David Magnus, Dr. HFM
roscience 6(12): 1239.
Van der Loos, Ms. Kim Karetsky, and Connie Stock-
Evans, J. W. Functional Magnetic Resonance Im-
ham for their invaluable input to this paper.
ages and Lie Detection, http://www.law.uh.edu/
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