HEC Forum (2008) 20(4): 311–314 DOI 10.1007/s10730-008-9081-6

© Springer 2009

Special Section on Clincial Neuroethics Consultation: Introduction

Paul J. Ford

With the expansion of the clinical neurosciences (neurology, neurosurgery, psychiatry, psychology, neuroimaging, neurogenetics, etc.) increasingly specialized ethics questions arise in the medical care of patients. The functional complexities of the brain have necessitated an interdisciplinary approach to diagnosing and treating diseases of the central nervous system (CNS) which in turn adds to the challenges of providing ethics consultation services in this context. Although many ethical issues related to CNS diseases have been raised in other contexts, there are important variations and permutations that necessitate further discussion of how these new types of neuroscientific knowledge and activity continue to pose challenges to ethics consultation services provided for clinicians and patients. In this special section of HEC Forum on Clinical Neuroethics Consultation, authors reflect on several aspects of practice in clinical ethics consultation related to complex illnesses of the central nervous system. Interestingly, the topics range from high technology intervention, to traumatic sports injuries, to questions of standards and practices. These papers push us carefully to reflect on the roles that clinical ethics consultants could play within the clinical neurological area. Neuroethics continues to gain popularity as a subspecialty in bioethics as evidenced by the emergence of several journals and a professional society. However, much of the international neuroethics dialogue focuses on neuroimaging research, enhancement technologies, the basis of morality in the brain, and free will. There has been less attention paid to the practical challenges in daily clinical practices related to those with CNS medical problems. The most robust literature in clinical neuroethics arises out of psychiatric ethics and out of the extensive discussion of therapy withdrawal on patients with severe alterations of consciousness. Issues in mental health have always captured people’s interest, but the work in this area has often _____________________________________________________________________________________ Paul J. Ford, Ph.D., Staff (Bioethics and Neurology), The Cleveland Clinic Foundation, Assistant Professor, CCF Lerner College of Medicine of CWRU, Department of Bioethics/ JJ60, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195; email: [email protected].

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been vague. In the end of life debates, many of the foundational bioethics cases involve patients with severe brain injury whose circumstances raise questions of a right to withdraw life sustaining treatment. In the context of end of life decisions for severe brain injury, one could argue that much of clinical ethics stems from concerns of clinical neuroethics. However, despite this early interest, the specific challenges and subtleties of clinical neuroethics have been relatively ignored by bioethics in favor of a continued expansion of a more generalized clinical ethics consultation agenda. Counter to this trend, the following articles push the boundaries of which topics we are discussing and expand the ways in which we can provide help in clinical situations by fully appreciating how the specific details of specialized topics can lead to better ethics consultation. The Perils of Ethics Consultation in Psychiatry The group of papers begins with an exploration of the pitfalls and perils of the soon to be released update of the Diagnostic and Statistics Manual (DSM V) for psychiatry. In the essay “Psychiatric Ethics Consultation in the Light of DSM V” Peter Horn argues that ethics consultants who provide consultation in psychiatry and mental health fields need to be aware of the underlying assumptions of DSM V. This will help the consultant to better highlight the values at stake in particular cases, especially values at stake that may be hidden or obscured by the appearance of pure objectivity. Further, the clinical ethics consultant may have a positive obligation to challenge and to provide input to the continuing development of future DSM revisions. It would seem that a greater obligation of contribution exists for consultants who regularly consult on mental health care cases. Horn provides an important service by highlighting the set of roles that consultants might play in cases and policy. His article also keeps in the fore the social implication of psychiatric diagnostic categories. Although clinical ethicists who are not mental health experts should not be in the business of providing diagnosis, they should provide advice and guidance based on as much understanding of the diagnosis as possible. Understanding the shifts between versions of the DSM may provide the consultant the hints needed to highlight contested areas, in which patients may reasonably benefit from second opinions or to challenge the diagnosis. Navigating Ethics Consultation when Psychiatry Meets Neurosurgery Given the advances in neuroimaging and stereotactic neurosurgery, there is once again great hope that neurosurgical interventions, in particular

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implantation of electrical neuromodulators, may alleviate the suffering of those with debilitating psychiatric illness. Even given all the caveats raised in the first article about the social influence and implications of diagnostic categories, many individuals with psychiatric diagnosis are horribly debilitated with strong indication of physiological causes or at least that the resulting suffering can be significantly alleviated through physiological alterations. In “Deep-Brain Stimulation for Depression” Walter Glannon explores tough questions related to the emerging use of neuromodulators for the treatment of refractory depression. Even though Deep Brain Stimulation (DBS) is only available through research protocols for depression, the initial studies have shown great promise in alleviating symptoms for selected people with moderate to severe depression. Glannon particularly focuses on the question of how we should go about consenting patients for implantation of these devices. The usefulness of the ethics consultant in particular cases of patient consent may be largely dependent upon the consultants understanding of the technology and practices revolving around DBS systems. One could ask if clinical ethics consultants are in a good position to act as consent monitors or patient advocates during the consent process for placement of these complex neuromodulators. This use of ethics consultation may provide an unnecessary process that gives a false sense of security for clinicians. The role of ethics consultant, or ethics committee, in developing the consent procedures for clinical use of a particularly innovative technology is a situation in which ethics consultation might be best used. An aspect of Glannon’s account of the fictionalized case is that an ethics committee, rather than an individual consultant, reviews the process. The expertise of creating a system of good medical practice with checks and balances for this patient population is important. We must provide access to therapies with good potential for benefit without discrimination against those with psychiatric diagnosis. However, this must be balanced against the recognition that a subpopulation within those with a psychiatric diagnosis may lack the proper capacity to fully appreciate the risk of harm and uncertainty of benefit. For these subpopulations we must provide robust protections to assure they are not put at inappropriate levels of risk. Preparing for Ethics Consultations in Sports Moving away from the psychiatric and emerging technologies the third paper takes up issues of concussions in professional football. Clinical ethics discussion of traumatic neurological injury often occurs only after patients have received a devastating injury from some type of accident or violent act. In “Concussions, Professional Sports, and Conflicts of Interest” Daniel S.

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Goldberg explores an interesting example of the various obligations in an outpatient setting, and in policy, where a clinical ethicist might need to provide advice regarding a physician’s role in a complex social, financial, and relational context. Concussions are expected occurrences in many sporting activities. We have many socially sanctioned and reified activities like these where glory, fame, or fortune may ride on putting one’s neurological health at risk. Goldberg focuses on professional football, but could easily have chosen sports such as ice hockey, fighting, soccer, or rugby for their frequent head injuries. The issues raised need not only be related to professional sports, but also apply to high school, collegiate, and national endeavors in sport. As with the previous papers, Goldberg has an interest in drawing a relevance of the issues to the individual ethics consultant who might be consulted by a sports medicine physician as well as the larger policy issues in which the consultant my be influential. The ethics consultant can provide guidance to the clinician regarding the level of paternalism or protectionism that would be ethically permissible in situations where a patient may be disempowered to protect himself from long term harm. Diseases, illnesses, and injuries affecting the CNS alter persons in ways that directly impinge on a particular self’s experiences of the world and judgements about best interests. The stakes are often very high and unfortunately great degrees of uncertainty regarding extent of permanence in functional loss pervade most neuro-clinical decisions. Paying careful attention to the particularities of neuro-clinical challenges can augment ethics consultants’ ability to avoid importing unfounded assumptions from their experiences and training from consultation in diseases of other organ systems. The neuro-clinical ethics consultation provides one example of the broader need for the field of ethics consultation to further develop by recognizing the important differences in type of consults provided in various clinical contexts.