Neuroethics (2011) 4:251–259 DOI 10.1007/s12152-010-9089-x

ORIGINAL PAPER

Is There a Need for Clinical Neuroskepticism? Eran Klein

Received: 2 June 2010 / Accepted: 4 August 2010 / Published online: 17 August 2010 # Springer Science+Business Media B.V. 2010

Abstract Clinical neuroethics and neuroskepticism are recent entrants to the vocabulary of neuroethics. Clinical neuroethics has been used to distinguish problems of clinical relevance arising from developments in brain science from problems arising in neuroscience research proper. Neuroskepticism has been proposed as a counterweight to claims about the value and likely implications of developments in neuroscience. These two emergent streams of thought intersect within the practice of neurology. Neurologists face many traditional problems in bioethics, like end of life care in the persistent vegetative state, determination of capacity in progressive dementia, and requests for assisted suicide in cognition-preserving neurodegenerative disease (like amyotrophic lateral sclerosis). Neurologists also look to be at the forefront of downstream clinical applications of neuroscience, like pharmacological enhancement of mental life. At the same time, the practice of neurology, concerned primarily with the structure, function, and treatment of the nervous system, has historically fostered a kind of skeptical attitude toward its own subject matter. Not all problems that appear primarily neurological are primarily neurological. This disciplinary skepticism is generally clinical in orientation and

E. Klein (*) Department of Neurology, L226, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA e-mail: [email protected]

limited in scope. The rise of interest in clinical neuroethics and in neuroskepticsim generally suggests a possible broader application. The clinical skepticism of neurology provides impetus for thinking about the appropriate role for skepticism in clinical areas of neuroethics. After a brief review of neuroskepticism and clinical neuroethics, a taxonomy of clinical neuroskepticism is offered and reasons why a stronger rather than weaker form of clinical neuroskepticism is currently warranted. Keywords Neuroethics . Neuroskepticism . Neurology . Clinical ethics . Clinical neuroethics . Neuroscience

Just to amuse myself, and keep the good people busy, I ordered them to build this City, and my palace; and they did it all willingly and well. Then I thought, as the country was so green and beautiful, I would call it the Emerald City, and to make the name fit better I put green spectacles on all the people, so that everything they saw was green [1].

Introduction A neurologist can be said to see the world through brain-tinted spectacles. An older man walking down

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the street with asymmetric armswing. Parkinson’s disease? A woman interviewed on the local news with monotonous speech. Right hemisphere dysfunction? A new colleague at work with a crooked smile. A distant stroke? A clinic patient’s episodes of blurry vision, headache, and fatigue. A new case of giant cell arteritis? It is a peculiar skill to come to see others through the functioning (or dysfunctioning) of the nervous system. Yet it is, arguably, the quintessential skill of a neurologist to encounter others in this way, a skill that often, though not always, pays dividends. This peculiar skill is incubated typically within a rather brain-centric domain of medicine. Neurologists learn to be neurologists surrounded by basic neuroscientists, neuroradiologists, neurosurgeons, neuropsychologists, psychiatrists, and others with specialized knowledge of the brain. Immersed within this environment, the donning of brain-tinted spectacles becomes second nature. “Of course one must think of such and such a neurologic diagnosis first when presented with those symptoms.” Clinical education transitions the neurologist-in-training from abstract study of the nervous system (the “ology” of the “neuro”) to a practical prioritization of the brain in diagnosis and treatment: think brain first. Over time, the neurologist’s spectacles can become rather affixed. The skill of the neurologist runs aground, however, if not traveling alongside a healthy skepticism, what Dewey called the mark and pose of the educated mind [2]. Medicine is replete with neurological mimics. That which appears primarily neurological, sometimes - in fact often - is not. An old shoulder injury can account for asymmetric armswing, personality or disinterest for reduced prosody of speech, a childhood admiration of Harrison Ford for a rye smile, and the need for new glasses and more sleep for the triad of blurry vision, headache, and fatigue. A single-focused pursuit of a neurologic cause of symptoms, when a primary non-neurologic cause is more apt, can be misleading and sometimes costly. The ability to distinguish between that which looks primarily neurological and that which is primarily neurological, if not part of the neurologist’s peculiar skill, is requisite to its proper use. Bioethics is currently enamoured of ethical problems related to states and conditions of the nervous system (much of which currently runs under the label of “neuroethics”) [3, 4]. For a

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neurologist with spectacles firmly and unabashedly attached, this neurophilia may seem perfectly a propos.1 Developments in neuroscience, broadly understood, are having and will continue to have important ethical implications that deserve attention. Many of these implications, still largely underappreciated, will be felt in and around clinical medicine, particularly neurology. But such neurophilia also raises concern. A tendency to cast an increasing number of problems in bioethics as “neuro” problems may lead, as it does analogously in clinical medicine, to distortion. Not all ethical problems that involve the brain are necessarily best approached in terms of the brain. Some form of neuroskepticism is needed in bioethics. The challenge is to arrive at an appropriate kind. The aim of what follows is to explore this question along a narrow, but practically relevant dimension: clinical bioethics. Clinical ethics problems involving pathological conditions of the nervous system represent a domain ripe for annexation by the “neuro.” The term clinical neuroethics already has a presence in the literature [6–9]. After a brief discussion of what is meant generally by neuroskepticism and by clinical neuroethics, a notion of clinical neuroskepticism will be proposed. I argue that clinical neuroskepticism can take different forms and that these forms can usefully be mapped onto views of different strengths — weak, moderate, and strong. A review of these different forms of skepticism suggests that a stronger rather than weaker form of clinical neuroskepticism is currently warranted. This exercise and its conclusion, though ostensibly concerned with clinical bioethics, may have implications for those interested in neuroscience and ethics more generally.

Typology of Neuroskeptism The last decade has seen a proliferation of neurologisms [10]. Neuromarketing [11]. Neuroaesthetics [12]. Neurolaw [13]. The application of the “neuro” prefix across disparate intellectual domains has occurred absent a clear articulation of what makes activities distinctly “neuro” in any non-trivial sense, 1

Though Trout’s recent introduction of the term neurophilia [5] is decidedly critical, my use of the term is less so.

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as well as absent a due appreciation of existing disciplines from which these “new” neuro activities arise [14]. The emergence of neuroskepticism as yet another entry in this linguistic neurofication of discourse (a sin of which I am now wholly guilty) is hardly surprising.2 Along with the proliferation of “neuro” terms comes the need for linguistic resources suited to critique of this proliferation and the activities so named. Neuroskepticism is the most obvious member in what might be viewed as a family of “neuro” critical terms. No consensus definition of neuroskepticism has yet to emerge. Jonathan Marks has recently suggested the term to mean “a perspective informed by science studies scholarship that views with some healthy skepticism claims about the practical implications and real-world applications of recent developments in neuroscience [16].” This definition keenly locates the target of skepticism at the level of individual claims. Popular culture and academic literature are increasingly punctuated by claims about what “neuroscience is now able to do.” Notwithstanding the many benefits that recent work in neuroscience has afforded human understanding and human health, neuroscience has lent itself, perhaps more so than other sciences, to presentation in terms of individual claims shorn of context, scientific and otherwise. A claims neuroskepticism is perhaps the most obvious form of neuroskepticism.3 Neuroskepticism can take as its target more systematic features of neuroscience as well. The 2

The recent penchant for attaching favored prefixes (“neuro”) to familiar terms is not a practice to which those of a neuroscience bent are more prone. One sees the proliferation of neologisms, for instance “geneticization,” [15] surrounding genetics in the later part of the 20th century. 3 It is important not to conflate a skeptical approach to neuroscientific claims to a rejection or refutation of such claims. Good science and cogent argument are the ultimate arbiter of the merit of individual claims. A skeptical approach, rather, is a demand for attention to the level of rigor in evaluating such claims. At minimum, skepticism requires that claims of interest (here, claims about the implications of neuroscience) receive equitable evaluation. Claims of interest should be subject to no less rigorous evaluation than is found in relevantly similar cognate domains. A skeptical approach, arguably, also may require higher levels of scrutiny or evidence at times, such as when the context in which claims are made and evaluated subverts reasonable evaluation (e.g., the unique psychological “pull” of brain imaging).

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generative systemic features can be of different types: disciplinary, evidentiary, or methodological.4 Skepticism can arise as to disciplinary boundaries within neuroscience or within areas of inquiry about neuroscience. Particular domains in neuroscience, or how their boundaries are drawn, have raised skeptical concerns. For example, skepticism of mental illness and professional activities surrounding it (e.g., development of diagnostic categories and methods of treatment) has long been a challenge faced by psychiatry [17]. Skepticism also has arisen about the boundaries of inquiry about neuroscience. The most obvious of these is given voice in recent debates over whether neuroethics warrants status as an independent field or discipline (rather than, say, a subsidiary or dependent area of interest extending across existing fields) [18, 19]. Can the boundaries delimiting nonscientific concerns about neuroscience (e.g., neuroethics, neurolaw, neuroeconomics, etc.) that have grown up of late bear critical scrutiny? Is there a conceptual coherence underlying these newly minted activities or would they come apart or meld together if pragmatic pressures (e.g., popular interest in the brain or proximity to substantial neuroscience funding) were removed? Categories of argument or evidence commonly adduced in neuroscience generate skeptical worry of a different sort. Various forms of inference made on the basis of emerging neurotechnology (most notably functional MRI) about thought patterns, personality, or moral sensibilities, provide recent examples of this. Doubt as to whether certain kinds of inference can be made from functional imaging data has attended this work since its inception [20]. Skepticism about the proper use of images, narratives and metaphors to motivate normative concerns about neuroscience is another related form of systemic worry. The apparent illumination purchased by turning to popular linguistic resources (e.g., “neuroscientific narratives” and “neuroscientific imaginaries”) can be deceptively shallow, if not at times distorting [16]. Types of systemic neuroskepticism identified here — disciplinary, evidentiary, methodological — are not wholly separable. Disciplines are understood, at least in part, in terms of their standards of evidence or the methodological tools they employ. And methods are inextricably bound up with the forms of evidence to which they are suited. Nonetheless, there is some value — and at least prima facie plausibility — to separating these out and treating them as separate targets of skepticism. 4

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Finally, systematic skepticism can take as its target particular favored methods of inquiry. These methods may come with well-established pedigrees, e.g., the use of moral intuitions in the study of normative decision-making [21]. Or they may be relative newcomers, such as correlation of genetic or molecular markers and social behavior [22]. Skepticism about methodology can be broad or narrow in scope. The concern may be with individual methods, for example specialized EEG in the study of deception [23]. Or the concern may be more general, with the overall methodological orientation to a given subject matter. Problems or particular sets of problems can be approached, understood, and conceptualized from a particular standpoint. Skepticism can arise over the value of taking one of these particular methodological orientations. The general methodological worry — doubt that the “neuro” ought to be the default orientation in particular contexts — is a particularly important and appropriate one for those in clinical bioethics. Many of the ethical issues that exercise those in neuroethics (with some notable exceptions, e.g., brain stimulation and pharmacological enhancement) are not yet pressing problems in clinical medicine. For those in clinical ethics to take issue with current methods that may one day generate problems “at the bedside” seems premature (and maybe inappropriate). Nonetheless, methods currently being employed in neuroscience have important implications for clinical medicine, even if many specific implications are not yet foreseeable. Methods embody an orientation to subject matter. Neuroscientific methods that take human beings, or in clinical contexts, patients, to consist of a particular kind of thing (e.g., a complex of psychological states, a network of neural activity, a balance of neurotransmitters), frame how patients and their problems are and will be approached and understood. The remainder of this essay will focus on whether a general orientational skepticism is warranted in clinical ethics, and if so, what form it should take. This is not to claim that other forms of systematic neuroskepticism are not important to clinical bioethics. Nor is it to suggest that some level of skepticism might not now be appropriate for certain claims made in current clinical practice (e.g., pharmacological enhancement). The focus on orientation is narrower, but in an important sense, also more fundamental. The

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general orientation to understanding the brain embodied in neuroscience does and will continue to shape the methods that clinicians find appropriate to bring to clinical care. It is not too early for those in clinical ethics to take a critical eye to neuroscience and ask: is there a need for clinical neuroskepticism?

Clinical Ethics and Neuroethics Discussion of neuroskepticism has been kept to this point at a rather abstract level, but a more concrete turn is now in order. Clinical bioethics is an area within bioethics of which most are familiar. It is the name given to that set of ethical problems that arise out of individual patient-practitioner interactions. Did Dr. Nguyen provide his patient enough information to make an informed decision? Would it be abandonment for Dr. Ignacio to “fire” her non-adherent patient? Who is the best surrogate decision-maker for Mr. Leeds? Problems in clinical bioethics inform and are informed by bioethics more generally, but the practice of clinical bioethics remains, in practical terms, relatively distinct. The neurological is woven deep into the history and practice of clinical ethics. Many of the paradigm cases in clinical ethics — Karen Ann Quinlan, Nancy Cruzan, Theresa Schiavo, Baby K, Baby Doe, Elizabeth Bouvia, Joseph Saikewicz — center on a neurologic diagnosis.5 The contribution of the neurological to clinical ethics has not been fully appreciated [24]. Early and continuing debates over methodology in clinical bioethics — for example, principlism versus casuistry — refer to or are tested against cases of this sort [25]. No bioethics textbook would be complete without discussion of the particular issues that dysfunction of the nervous system generate. It is hard to imagine what modern bioethics would look like without the inclusion of these types of cases. The last decade has seen the rise of neuroethics as a distinct category of interest in bioethics. In less than 10 years, the nascent “field” of neuroethics has traveled from inaugural conference to institutionalization [26]. It now has dedicated journals, societies, 5 Quinlan, Cruzan, and Schiavo carried diagnoses of persistent vegetative state. Baby Doe was diagnosed with Down’s Syndrome, Baby K with anencephaly, Bouvia with cerebral palsy, and Saikewicz with mental retardation. For discussion of these and other “classic” cases in bioethics, see [6].

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and research centers (and even historical reflections on its origins [27]). Throughout the short lifespan of neuroethics, clinical ethics, however, has played a more secondary role than it has in bioethics more generally. The kinds of problems exercising writers on neuroethics have been less straightforwardly clinical (e.g., incidental research findings, mental enhancement, cognitive privacy). While not ignoring clinical implications of neuroscience, the focus for the most part has been elsewhere. The emergence of the term clinical neuroethics within the neuroethics discourse marks what may be a change in that focus. Clinical ethics problems involving dysfunction of the nervous system, once described solely as bioethics problems, are shifting to become clinical neuroethics problems. The most recent edition of a prominent textbook on neurology and ethics endorses this shift, labeling chapters on disorders of consciousness, dementia, mental retardation and the like as the “clinical neuroethics” section of the book [6]. But even where the term clinical neuroethics has not yet been taken up, interest in clinical ethics is evident. Neuroethics anthologies include entries on clinical ethics [3]. Bioethics anthologies include brain-related articles of both clinical and scientific orientations [28]. And articles that include “neuroethics” in the title or are otherwise identified by the term, and whose content would have not long ago fallen under the umbrella of bioethics, are not hard to find. The line between brain-related clinical bioethics and neuroethics (or clinical neuroethics) is beginning to blur. Behind this shift lies an implicit presumption. The presumption is a prioritization of content over method. Clinical ethics problems involving pathological conditions of the brain (e.g., stroke, multiple sclerosis, dementia) are based on function and dysfunction of the nervous system. Standard problems in neuroethics (e.g., incidental research imaging findings, mental enhancement, cognitive privacy) involve function or dysfunction of the nervous system as well. Both clinical ethics and neuroethics share a similar content. Neuromuscular transmission. Hemispheric integration. Neurodegeneration. Electrical excitability. Where content is similar, it can be argued, methodological approach ought to be similar. Since the brain is afforded priority in neuroethics, it ought to be afforded a similar priority in the clinical realm when dysfunction of the nervous system is present.

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One might call this the presumption of neurological priority. And it is this presumption that calls for some degree of skepticism.

Clinical Neuroskepticsm The aim to this point has been to situate a notion of clinical neuroskepticism within the context of clinical bioethics. Now it is worth looking at the notion of clinical neuroskepticism at a more fine-grained level. The remainder of this paper will proceed by way of examining clinical neuroskepticism along a continuum, from a weak form to a more robust form. The parsing of clinical neuroskepticism along a continuum will prove a useful heuristic tool for elucidating the commitments involved in taking a neuroskeptical approach.6 It will also, in the end, lend credence to a stronger form of clinical neuroskepticism than at first may seem warranted. Weak Clinical Neuroskepticism On any mainstream philosophy of mind, the change brought by illness — in values, preferences, beliefs, commitments, and the like — is redeemable in change at the level of the brain. For every token change (to invoke the technical term) at the level of mental life there is a corresponding change at the level of the brain. The token-token identity thesis is a relatively uncontroversial one in the philosophy of mind (certainly less so than other kinds of identity theses) [29]. Whether the experience of pain is identical to the firing of C-fibers (or an equivalent physiologic process) may be a matter of dispute, but that change in the experience of pain is attended by some change at the level of the brain is not [30]. Analogously, regardless of how we understand the changes to our mental life that the experience of illness ushers in — often taken as the purview of bioethics — there are corresponding changes in the brain. There is a sense in which bioethics can be reduced, at least at one level, to the brain. 6

The focus here is on the range of individual skeptical commitments not where individual views fit along this continuum. There is no reason to suspect that a more fleshed out heuristic tool, the outlines of which are being sketched here, may not ultimately facilitate such a mapping, but that is not my intention.

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Notable recent efforts have been made to marshal the resources of neuroscience for the study of morality and moral judgment. A significant and vigorous literature has grown up around such efforts, shaped in large part by the early work of Joshua Greene and colleagues with functional magnetic resonance imaging. (fMRI) [31]. In a relatively short time, the study of ethics through neuroscientific means (particularly imaging techniques like fMRI, PET, EEG), has expanded rapidly in scope. This literature now includes work on prejudices [32], moral emotions [33], and the sense of fairness in moral judgment [34]. Despite the burgeoning interest in ethics and ethical judgment more generally, similar empirical study of moral judgment in bioethics has been more sparse. One imagines that though bioethics now is relatively virgin ground for such investigations this will likely not long be the case. The turn of neuroscience to the empiricallyoriented study of bioethics immediately raises concern about scope. If every morally relevant change at the clinical level (i.e., the experience of illness) is attended by a change at the level of the brain, does not the whole of clinical bioethics potentially become the subject matter of neuroscience, or more specifically, neuroethics? How does neuroethics not threaten to swallow clinical bioethics whole? The function (or dysfunction) of other organ systems (kidney, liver, immune) may have relevance to particular discussions in bioethics, but these at least seem to have natural boundaries, established by tradition if not discipline, that the study of the brain does not. Nephroethics, hepatoethics, and immunoethics, at some level, stretch the bounds of sense. A neuroethics that reaches deep into every problem in bioethics may not. The skeptical worry here starts to come into view. Not all changes in the brain brought on by the experience of illness would seem to warrant the label of neuroethics. Some processes, like ignoring a honking car outside a hospital room window, though having neural correlates, are clearly irrelevant in all but the rarest of circumstances. From a quantitative standpoint, most brain states are not relevant to problems of interest in clinical bioethics. Those states of the brain that are relevant are so because they carry moral properties given meaning by particular moral contexts. This is reason enough to resist the ambition to make the brain the orienting category for all of

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clinical bioethics.7 At minimum, this weak form of neuroskepticism is in order. Moderate Clinical Neuroskepticism Medical cases are typically presented in terms of a primary diagnosis. Patients have cancer, or liver failure, or bacterial sepsis, or cardiac failure, or emphysema. They also, of course, have other conditions, some related to their primary condition and some not. These conditions are given a subsidiary role in the structured case presentation that becomes second nature to medical practitioners. They are relegated to prepositional phrases. The patient has cancer with neurologic involvement (i.e., brain or spinal cord metastasis). The patient has liver or kidney failure with associated encephalopathy (i.e., confusion). The patient has a systemic infection with consequent delirium. The patient has cardiac and pulmonary failure with attendant confusion. Clinical ethics cases inherit the structured presentation of clinical medicine. Even though the associated condition may be of greater ethical importance (e.g., impaired cognition), the presentation of the ethics case does not reflect this on its face. If a secondary diagnosis or symptom is really of greatest ethical importance, a mental transformation of sorts is needed to configure the case’s normative hierarchy.8 The extra effort needed to transform clinical ethics cases may seem unnecessary or even distorting. In the case of a confused patient with chronic kidney failure, problems with the brain (i.e., encephalopathy) are at least as important, perhaps more, than other features. The ethical issues raised by such a case cannot be adequately addressed without attending to the pathology of the brain. It would make just as much sense to approach such a case first as one of encephalopathy caused by kidney failure as it would kidney failure with associated encephalopathy. There would seem to 7 It may be the case that no one currently harbors such ambitions, or at least ambitions put so baldly, but it would be a mistake to take the view to be a straw man. A bioethics of brain states would seem to rest comfortably at the intersection of the push for greater empirical work in bioethics on one hand (see [35]) and the largely reductionist views of the mind (as evidenced by Patricia Churchland, for instance [36]) informing bioethics, at least as filtered through neuroethics, on the other. 8 Todd Chambers, in his The Fiction of Bioethics, discusses how the structure of cases in bioethics prefigures their evaluation [37].

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be benefit to taking such a case (or another like it) to be first a neuroethics case. There is no doubt that conditions involving pathology of the brain require the use of particular tools of ethical analysis. Ronald Cranford, who was the first to use the term neuroethics in the clinically relevant sense, did so to describe the unique skills of neurologists to address ethical dilemmas arising from pathological conditions of the brain [38]. Where the important ethical issues turn on conditions of the nervous system, the neurological should be given priority. The difficulty with yielding the neurological priority is that it is not always clear before submersion in the details and nuances of a case whether the neurological is the most important. That is, whether a case is best approached from the perspective of the nervous system or from another perspective will turn on the particular details of the case. Which details are most important from an ethical perspective cannot (or at least should not) be decided a priori. An approach to clinical ethics that gives priority to the neurological in all clinical cases involving the nervous system carries risk. The non-neurological features of a case may need to drive ethical analysis, even in cases in which dysfunction of the nervous system features prominently. This provides reason to be skeptical of giving the brain methodological priority. This warrants, what might be called, a moderate form of neuroskepticism. Strong Clinical Neuroskepticism Some cases in clinical ethics are clearly neurological. These are cases in which the primary disease is one of the nervous system and in which the most ethically relevant particulars of the case are directly connected to this diagnosis. Consider the features of a person with amyotrophic lateral sclerosis (ALS). Preserved cognition. Progressive neuromuscular failure of limbs and respiration. Dependency. Loss of privacy. In so far as these are the most important ethical features and ought to play most prominently in analysis of a case of someone with ALS, the clearest case for a neurooriented approach would seem to be made. It is easy to imagine that a neuro-oriented approach would be of value. Conceptual and methodological resources of a neurological sort brought directly to clinical problems would have an advantage in so far

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as they would be aptly suited to problems of the nervous system. One already sees interest in bringing the concept of free will, which current work in neuroscience is helping to refine, fruitfully to bear on clinical problems, like disorders of involuntary movement [39] and addiction [40]. And there are similarly examples of putting the philosophical notion of personal identity to use in discussions of advancing dementia [41]. With its own set of conceptual tools, a neurological approach to cases in clinical ethics would be a natural asset. At present, though, the tool box used for addressing brain-oriented clinical problems borrows heavily from other sources in bioethics. There is a rich history in bioethics of dealing with brain-related ethics problems. The paradigm cases (and many others less well known) have been approached with, what have come to be, well-developed ethical tools — both methodological (e.g., principles, impartial rules, narratives, paradigm cases) and conceptual tools (e.g., integrity, vulnerability, dignity, respect). It is hard to conceive of a neurological approach, at least one ready for use now, that would not need to import much of its ethical machinery from outside. This raises again a skeptical worry. This time, the skepticism is that a neurological approach to clinical ethics cases, even ones that are incontestably neurological, is best. This more robust form of clinical neuroskepticism stands on the assumption that a brain-oriented approach does not carry its own full range of ethical resources needed to address problems in clinical ethics. At present, this assumption is borne out. The assumption may not continue to hold going forward — and its support of a presumption of strong neuroskepticism may weaken — but this will depend in large part on how the field of bioethics responds to increasing interest in problems of the brain.

Concluding Thoughts Anjan Chatterjee in his “The promise and predicament of cosmetic neurology” provides a provocative vision of future medical practice awash in a sea of neurotechnology [42]. He imagines a time, perhaps not too far distant, when patients come calling on physicians (particularly neurologists) as purveyors of neurotechnology. Drug A for more productive executives. Drug B for more competitive high school

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athletes. Drug C for more trusting companions. In their journey to be made whole (again), patients will invest ever more hope in the promise neurotechnology. Chatterjee’s tale is a cautionary one for medicine and society: blindly traveling down the neurotechnology road, without honestly and earnestly grappling with ethical questions raised by neurotechnology, may yield a future for medicine that many would now think unacceptable. There is another, perhaps equally important, lesson to be drawn from Chatterjee’s cautionary tale. The future world in which patients seek help bettering themselves or parents come in search of a fix for their “defective” child will be one thoroughly colored by neuro terms. It will be populated by neurologists, neurosurgeons, neuroeducators, neurophilosophers, neuroeconomists, neurolawyers, and neuropolicy makers. It will contain neuroinnovations, neuroenhancements, neuromodulators, and neuroprostheses. It will be conceptualized in neuroreductionist, neurodeterministic, neurorealist, or neurosurealist terms. It will be governed by neurolaws and neuroregulations. It will be a world in which the neuro is pervasive, and yet, not necessarily illuminating. It is far from clear that a future world in which everyone wears neurospectacles is the best one available to us. Neuroscience has changed the way we understand ourselves and no doubt will continue to do so, often for the better. But it provides just one way to encounter the world. Enveloping ourselves in a discourse of the “neuro” — though perhaps seductive at times — can also crowd out other valuable ways of talking about and understanding ourselves and our place in the world. Sometimes talk of neurons, synapses, and circuits must give way to talk of open futures, distributive justice, and perfectionism. A healthy dose of neuroskepticism may be just what’s needed for medicine to travel along neurotechnology’s golden road. Acknowledgements During the preparation of this manuscript, the author was supported by a Greenwall Foundation fellowship. The author is grateful to David Tester, Daniel Sulmasy, Joseph Fins, Peter Whitehouse, and an anonymous reviewer for thoughtful comments.

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