Dr. Peter B. Reiner speaking at the Peter Wall Institute of Advanced Studies International Roundtable We are our brains, October 2013.
The current issue of the European Journal of Risk Regulation has the proceedings of a symposium on nudging, and it contains a set of insightful papers. The introduction by the editor says it best.
The EJRR starts the new year by hosting a pioneering symposium devoted to one of the latest policy innovations that is currently experimented in the United Kingdom and the United States: the ubiquitous, yet controversial, Nudge. This idea originates from the homonymous, 2008 best-selling book published by the economist Richard Thaler and the legal scholar Cass Sunstein. By building upon the findings of behavioural research, they refute the classic economic assumption that “each of us thinks and chooses unfailingly well”1 and they advocate the need for public authorities to nudge people to make decisions that serve their own long-term interests without however removing their right to choose.
At a time in which governments are taking considerable interest in the use of nudging, we have asked some of the leading authors who have already contributed to the literature surrounding the regulatory innovations, generally referred as New Governance, to share their ideas on this appealing regulatory approach.
In his opening essay, Nudging Healthy Lifestyles, Adam Burgess provides a critical assessment of the introduction of behavioural, nudging approaches to correct lifestyle behaviours in the UK. His thought-provoking analysis triggered a lively debate that has been framed along the subsequent essays signed by On Amir and Orly Lobel, Evan Selinger and Kyle Powys White, Alberto Alemanno and Luc Bovens.
The article by Alberto Alemanno, Managing Editor of the European Journal of Risk Regulation is a fulsome account of the propriety of nudging in the case of tobacco control (recently highlighted by Roland on these pages); that nudging in this instance overcomes many of the objections that are raised in the other contributions to the symposium.
I also liked Selinger & White’s analysis of nudging in the context of Brad Allenby and Dan Sarewitz’s insight on the three levels by which we should view technological fixes (as articulated in their excellent book The Techno-Human Condition, which I have written about before). In particular, they point out the naiveté of only considering shop-floor arguments, a topic we will return to again.
Hat tip to Marleen Eijkholt for alerting me to this symposium.
Image credit: Transcapitalist
Although the topic of cigarette packaging regulation may not leap immediately to mind when one thinks “neuroethics,” this Bob Greene opinion piece over at CNN nonetheless touched off a stimulating discussion among some of us at the Core recently. The neuroethics connection, in fact, struck us as quite natural: our group has researched (and blogged about) the ethics of “nudging” frequently of late, and, as I worded it when I first emailed the article around, “certainly the images at issue here are a kind of behavioural nudge.” The question that we grappled with was whether the kind of nudge that the graphic warning labels provide is warranted in the case of cigarettes. And, indeed, that discussion called my original characterization into question. Do these labels truly constitute a nudge – a subtle biasing technique that makes a particular option more cognitively accessible than another while preserving the freedom to choose between them – or are they something more akin to a “shove?”
As with any highly politicized issue, the question of whether cigarettes ought to be labeled with disturbing imagery is likely to be filleted into oblivion by pundits, bloggers, legal experts, economists, et cetera, et cetera. All I hope to do here, then, is sketch some ways in which the view from neuroethics – informed as it is by philosophy and the cognitive sciences – can shed some interesting and hopefully useful light on the question. Continue reading
The National Core for Neuroethics at the University of British Columbia is proud to present Dr. Adrian Carter, NHMRC Postdoctoral Fellow from the University of Queensland, for a talk entitled, “Should We Trial Deep Brain Stimulation for Addiction? The Case for Caution” on Tuesday, November 9th, 2010 at 11:00am. The talk will take place in the University’s Brain Research Centre Conference Room. All are welcome. Please see below.
NEUROETHICS SEMINAR SERIES 2010-2011
Should We Trial Deep Brain Stimulation for Addiction? The Case for Caution.
Adrian Carter, PhD
NHMRC Postdoctoral Fellow
The University of Queensland
Tuesday, November 9th, 2010
11:00am – 12:00pm
The UBC Brain Research Centre Conference Room
2211 Wesbrook Mall | UBC Hospital | Koerner Pavilion
Vancouver, British Columbia, Canada
Abstract: Deep brain stimulation (DBS) has been proposed as a potential treatment of drug addiction on the basis of its effects on drug self-administration in animals and on addictive behaviours in some humans treated with DBS for other psychiatric or neurological conditions. dbs is seen as a more reversible intervention than ablative neurosurgery but it is nonetheless a treatment that carries significant risks. I will review preclinical and clinical evidence for the use of DBS to treat addiction to determine whether its use is currently warranted, making the case for caution. Severely addicted persons who try and fail to achieve abstinence may, however, be desperate enough to undergo such an invasive treatment if they believe that it will cure their addiction. History shows that the desperation for a “cure” of addiction can lead to the use of risky medical procedures before they have been rigorously tested. In the event that DBS is used in the treatment of addiction, I will examine the minimum ethical requirements for conducting such a trial.
About the speaker: Dr. Carter is an NHMRC Postdoctoral Fellow in Public Health at UQ. He is particularly interested in the impact that neuroscience has upon notions of autonomy and responsibility in addiction, the use of coercion and the capacity to consent in addiction treatment, as well as the use of novel neurological technologies to treat, and possibly, prevent addiction. Dr. Carter has published numerous articles on these issues, as well as reports for the who, the European Monitoring Centre for Drugs and Drug Addiction, and the Australian Ministerial Council on Drugs Strategy.
Over at The New Republic, Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute, recently reviewed the controversial book Addiction: A Disorder of Choice by psychologist Gene Heyman. Heyman’s thesis is that conventional wisdom about addiction being a ‘disease’, or perhaps a ‘brain disease’, is incorrect. Satel quotes Heyman by saying, “that the idea [of] addiction [as] a disease has been based on a limited view of voluntary behavior.” Accordingly, addiction is not an “irresistible act”, as he claims the term ‘addiction’ implies, and is in fact a “disorder of choice”. [Note: I have not read Heyman’s book, so I will not comment on the book directly]. Indeed, Satel conveys Heyman’s position as one that is in opposition to perspectives from powerful public figures that support the view that “Addiction is a Brain Disease, and it Matters.” Satel agrees with Heyman’s position, namely that if addiction is a disease, it is a disease the person chose for herself.
Satel’s review of Addiction prompted a response from writer Sascha Z. Scolbic and Peter Scolbic (TNR’s executive editor), who argued that Satel was puting up a “straw man” argument. [See Satel’s reply to the Scolbic’s here].
According to Dr. Michael Krausz, the LEEF Leadership Chair in Addiction Research, chronic substance abuse and mental illness are of critical concern and pose significant challenges, especially when they are co-occurring. Dr. Krausz recently brought his international expertise in concurrent disorders – the dual diagnosis of mental illness and drug addiction – to the University of British Columbia to address the crisis in Vancouver’s Downtown Eastside where addiction, psychiatric illness and homelessness are rampant. Hailed as the poorest postal code in Canada, the Downtown Eastside is a microcosm of social problems where overdose and suicide are the leading causes of death.
At the “Neuroethics of Addiction” conference Dr. Krausz’s message was clear – treatment availability and access to those is need is seriously lacking in Vancouver. Dr. Krausz stated that he views the current situation as ethically problematic. For instance, he stressed that people with addiction and mental health issues have the highest unmet need for treatment but are often excluded from medical care, have increased rates of mortality and are amongst the most stigmatized and socially marginalized of groups. They suffer from many health-related burdens including HIV/AIDS, Hepatitis C, suicide, addiction-related cancers and homelessness. Nevertheless, a general lack of treatment and support is available. It it Dr. Krausz’s hope that the BC Centre for Excellence in HIV/AIDS will serve as a model for the creation of a similar Centre for Excellence, to provide focused resources and structures to facilitate state of the art addiction and mental health research in Canada.
Dr. Krausz described the current situation in Vancouver’s Downtown Eastside as being in “crisis mode” and lamented that emergency care is an insufficient reaction to the increasing needs of the community. He stated that part of the issue is the misconception that addiction is a moral issue – bad people making poor choices and until the public at large realizes that addiction is their problem too, no real change will take place.
Addiction is a brain disease. This is undeniably a bold and controversial statement and one which usually elicits varied reactions ranging from denial and skepticism to wholehearted agreement. The lack of consensus means that when Canada’s “neuroscientist in chief” is defending this view, people to sit up and pay close attention. During his recent talk as part of our “Neuroethics of Addiction” workshop, Dr. Anthony Phillips, the newly appointed scientific director of the Canadian Institutes for Health Research’s (CIHR) Institute for Neuroscience, Mental Health and Addiction (INMHA), explored how the brain networks and chemistry change as a result of repeated drug abuse. Dr. Phillips explained that people who abuse drugs are in the process of changing their brain chemistry (mainly through fluctuations in dopamine levels), which has semi permanent effects on decision-making processes.
From the data Dr. Phillips presented, it is clear that the brain plays a role in addiction. The ‘reward network’ and dopamine-glutamate system function pathologically such that basic needs such as food are ignored and seeking a particular drug is prioritized. But is addiction only a brain disease? I think it would be shortsighted to conceptualize the condition in that way. In addition to brain activity, socioeconomic, psychological and political factors, among others contribute to onset of the addictive behavior as well as to the disease course itself. This is not to say that investigating the neuroscience of addiction and addictive behavior is not a worthy endeavor. After all, Dr. Phillips expressed hope that research on the neuroplasticity (the brain’s ability to change itself) may have important implications for treatment of addiction. The contributions that science can make towards understanding and managing addiction are undoubtedly valuable. It is important, however, to acknowledge the complexity of the condition and avoid reductionist perspectives on addiction.
There was no doubt in my mind that Professor Wayne Hall was the ideal person to give the plenary talk at our Neuroethics of Addiction conference. He boasts an impressive track record as the former director of the Office of Public Policy and Ethics at the Institute for Molecular Bioscience and Director of the National Drug and Alcohol Research Centre at the University of New South Wales. Currently, Prof. Hall advises the World Health Organization on issues ranging from the health effects of cannabis use, to the effectiveness of opioid substitution treatment, vaccines against drug addiction and the ethical and social implications of addiction neuroscience research, to name but a few. He has published extensively in the area of addiction, neuroscience and ethics (and is lead author on an eloquent editorial by the same name), and draws upon an interdisciplinary toolbox of public health, sociology, neuroscience and bioethics in his thinking.
Professor Hall’s lecture focused on two areas. Broadly, he presented an overview of some ethical and social implications of: 1) recent neuroscience research on addiction, and 2) a “brain disease” concept of addiction, and the effect this concept may have on addiction treatment, prevention and drug policy, neuro-enhancement, and privacy. Although the title of his presentation suggested a balanced appraisal, Professor Hall weighed in for the most part on the potential “negatives” of neuroscience research in addiction. The majority of the talk was recognizable to those familiar with Prof. Hall’s neuroethics work, particularly the important research he has conducted with his student Adrian Carter.
One area that I found particularly interesting was the discussion of the potential implications of understanding people who have an addiction to be biologically vulnerable. Here, Hall focused on the debate over the commonsense perspective of addiction as an immoral choice, versus the medical brain disease view, which posits that addiction is a condition akin to other medical illnesses such as schizophrenia or cancer – the latter promoted by many high-profile scientists such as the National Institute on Drug Abuse’s director Nora Volkow and Alan Leshner of the American Association for the Advancement of Science. This aspect of Prof Hall’s presentation was a perfect follow-up to the first speaker of the day, neuroscientist Dr. Anthony Phillips, who presented with the controversial title, Addiction is a Brain Disease. Hall argued that these brain disease endorsements and categorical views of addiction may actually present more drawbacks than benefits. For example, if individuals living with an addiction are brain-diseased, it may be argued that they lack the capacity to provide free and informed consent to research and treatment (see: Carter and Hall, 2008). Second, a focus on a disease model may instigate misguided efforts towards heroic and “spurious biological remedies” to “cure” addiction, and thus a premature enthusiasm for treatments such as naltrexone which may be used to justify coerced treatment, or as Art Caplan has suggested, to “deny autonomy in order to create it” (for a recent debate in the journal Addiction on this topic see Caplan 2008; Hall, Capps, and Carter, 2008; and Buchman and Russell, 2009). Although Prof Hall did not refer to this directly, some of his arguments in many ways reflect earlier exploration and concern around the social and ethical implications of psychiatric genetics, in particular how a genetic model of mental illness may increase stigma (see for example some of Jo Phelan’s work).
Although Professor Hall mainly focused on the potential negative ethical and social implications during his presentation, he did spend some time emphasizing the potential positives of addiction neuroscience research. These included the possibilities of new treatments, preventative measures such as genetic screenings and drug vaccines, maintenance therapies that have a lower overdose risk, and that advances in pharmacogenetics may lead to more precise treatment matching. Further, despite the drawbacks, Hall stated that a disease model may lead to a less punative response to addiction and may increase funding for research. Ultimately, the takehome message of the lecture was that addiction neuroscience is an incredibly exciting field and his concerns do “not justify a moratorium.” Hall does, however, encourage moderation of the therapeutic and preventative claims made by research, and suggests that neuroscience researchers ought to reflect upon the potential implications of their work.
Thanks to everyone who joined us for our meeting at the Wosk Centre for Dialogue in Vancouver on April 14, 2009. As mentioned during the meeting, members of the National Core for Neuroethics will be blogging about the plenary sessions in the coming days. Please post your thoughts on the meeting right here on this blog. We look forward to “reading your thoughts!”