Brain-imaging technology has been an invaluable tool in helping researchers understand the relationship between brain structure, functions such as speech and memory, and human behavior, as well as in providing new ways to diagnose and treat diseases. But these advances into the workings of the human mind are also raising ethical questions regarding how such technology can and should be used for other purposes. For example, should an employer be allowed to scan a job applicant for depression, racism, or for the risk of developing Alzheimer’s disease? Should a defendant on trial be required to undergo brain scanning for lie-detection purposes? What if a woman wants to know if her fiancé is potentially abusive? Even if these uses were deemed ethical or legal, is the technology truly ready for them?

Neuroethics has become a hot field within academia and has been the focus of a handful of recent conferences, including last year’s President’s Council on Bioethics session that delved into the topics of neuroscience, neuropsychiatry, and neuroethics. While imaging technology can provide us with an enormous amount of information about the brain and cognitive functioning and maybe even moral reasoning, it cannot tell us everything, according to Judy Illes, PhD. “Studies of moral reasoning, well beyond more traditional studies of memory and language, for example, are very complex in that [moral reasoning] is intertwined with who we are as people and our self-identity, our values, and our emotional perspective on life,” she said in an interview with Neurology Reviews. “Neuroimaging can give us a lot, but it can’t give us all. As long as imaging experiments are done with good critical thinking behind them, driven by proper scientific hypotheses, and have all the necessary precautions in terms of human subjects’ protection, I don’t think there is a limit to understanding the biology of how we think and are. The more I can understand about my spirituality through my biology, the happier I am. We know that there are others who are more fearful of having a biology for the intangibles of our life, and we have to respect those positions. I don’t share that position, however.” Dr. Illes is a Senior Research Scholar and Director of the Program in Neuroethics at Stanford University’s Center for Biomedical Ethics in Stanford, California.

IMAGING FOR NONMEDICAL USES

Dr. Illes expressed concerns about imaging technology being used prematurely and cited such examples as employment screening, selecting great athletes of the future, and courtroom use. “Clearly, the potential for using the technology properly exists,” she said. “What may happen, though, is that its improper uses will occur first because of the hunger of our society for innovation. History shows that we sometimes run with technology in the public domain before it is really ready.”

Howard Gardner, PhD, Hobbs Professor of Education and Cognition at the Harvard Graduate School of Education in Cambridge, Massachusetts, believes that the risks go hand in hand with the benefits. “Earlier diagnosis [of diseases] (ie, amyotrophic lateral sclerosis, Huntington’s chorea, Alzheimer’s disease, etc) is of little use in the absence of interventions,” Dr. Gardner told Neurology Reviews. “There is the risk of early labeling—‘He/she will not be able to read’—and differences do not always mean deficits. My brain may look different from the norm at six months, but I may well be able to learn to read despite these differences.”

BRAIN SCANS FOR EDUCATION

On the other hand, education is one nonmedical area in which neuroimaging could play a positive role—for instance, in helping us understand certain childhood disorders better, such as problems with reading and attention deficit disorder (ADD), noted Dr. Illes. “Researchers are beginning to discover early markers of cognitive deficits, such as reading problems,” said Dr. Illes. “I have no doubt that similar early markers will be discovered for other cognitive deficits, ranging from problems with mathematical reasoning to problems with musical perception. Alert to possible problems, educators and therapists can design interventions that can circumvent or mitigate the effects of these deficits.... Down the road, the technology [may] advance to the point that it can be beneficial for individual children—customizing educational strategies for them, depending on the different kinds of intelligence, using Gardner’s Theory of Multiple Intelligences, for example.”

Dr. Gardner’s Theory of Multiple Intelligences is a critique of the notion that there is a single general intelligence, which presumably reflects the actions of specific genes and results in particular brain configurations. The theory breaks down intelligence into multiple categories. “I believe that the brain/mind is better described as a set of relatively autonomous computational devices,” he said. “A person may be strong in linguistics but not spatial intelligence or vice versa. Our knowledge of the brain, brain development, and genetics is vastly greater now than when I propounded this theory 25 years ago. That said, I think that the weight of evidence is quite supportive of the general claims of the Multiple Intelligences theory.

“Brain scanning should indicate both varying potentials for each of the intelligences early in life, and the actual strength of each intelligence at a given moment (which will be determined by a multitude of factors). This is because the various intelligences have distinct neuroanatomic sites. For example, roughly speaking, linguistic intelligence is housed in the left frontal-temporal areas (in right-handed people), while spatial intelligence is localized in the right parietal areas.”

IN THE COURTROOM

Imaging techniques have already been used in criminal trials. In some cases, brain scans may even be required as part of the work-up of certain individuals accused of crimes. “What always has to be kept in mind is how complex the data are, given the paradigm used to acquire the information and the techniques used to analyze the results,” noted Dr. Illes. “We have to be careful that we don’t have judges and juries making decisions based on distilled-down images.... We’re still quite far from being able to use that kind of information properly in the courtrooms.”

Dr. Gardner expressed similar concerns. “I am very nervous about the use of brain scanning in the criminal justice system,” he said. “Just as we know that certain psychopathic individuals can lie without giving any signs that they are lying, I suspect that these same individuals will not necessarily give incriminating (brain- imaging) testimony. It is an interesting empirical issue whether your brain can lie as well as you can. But I think that the brain should be able to take the Fifth Amendment in the same way that humans can. I would prefer to see the criminal justice system work with the usual kinds of evidence that are permissible—testimony of other persons, particularly witnesses, circumstantial evidence, etc. I have not seen the movie Minority Report, but I have read 1984, and I worry about a society that is blind to privacy and is totally intrusive.”

SELLING BRAIN SCANS TO THE PUBLIC

A number of private companies have been selling brain scans directly to consumers, without requiring a physician’s referral. There is evidence, however, that demand for the scans may be waning after a fast start. A report in the New York Times in January documented the rise and fall of such clinics, whereby a number of them have already closed due to declining business.

Dr. Illes’ group began to take a closer look at some of these companies and used body CT scans as a baseline for understanding the direct to consumer marketing of imaging services. “We felt that that industry was quite far along and provided a very strong foundation for understanding what the future portends in terms of brain imaging,” she said. “Maybe what consumers are trying to do is buy privacy. We’re really not quite sure.... We have to think about why somebody who is fearful that he or she has become symptomatic would shun the traditional health care system and enter what is still some pretty unchartered territory in terms of these independent facilities. They are not regulated now. There’s a lot that we don’t know. There’s great variability in the kinds of services that they provide, how they communicate with patients, and what follow-up is, if in fact there is a positive finding. How do individuals now enter the traditional health care system with a positive finding from an independent facility? There are issues of justice and access for all people.”

Thus far, many of the companies that offer private body and brain scans exist mostly on the two coasts, in areas of wealth and high education levels. Dr. Illes is unhappy with a lot of the advertising that she is seeing from them, “because we feel that the advertising doesn’t fully inform prospective consumers of all the risks and doesn’t urge them to seek further advice before purchasing one of these scans in the same way that drug selling does.... Patients should be urged to discuss with their primary care physician about whether this is a good idea or not. There should be some standards in place for how many times somebody should go back and have a repeat scan.”

A few facilities also sell functional brain scans, and Dr. Illes said that these companies appear to promote brain scans for two populations. One such population is for parents who are fearful of the academic underachievements of their children, “and so to see if perhaps there is a biologic reason why these children are not performing well, and maybe there is some evidence of ADD,” she said. At the other end of the spectrum are those individuals who are fearful of developing memory loss and whether it seems to be suggestive of Alzheimer’s disease. “In both cases, we don’t think these services are ready for prime time in the way that they are being sold,” Dr. Illes added.

“Clinical trials have not been done.... Even if we were to have the technology and be comfortable with its readiness for its scientific and medical applications, we have to think from a neuroethics point of view, what resources are then available for translating that new information into practical implementation on the receiving end? Are these people going to take scans of their children into their high school principal, to the district supervisor? How are they going to utilize this information? Is it going to create a life-long stigma in children? There is a host of really important questions that need to be dealt with proactively before this goes any further.”

Citing the potential for abuse and misuse of imaging technology, Dr. Gardner said that he opposes the sale of brain scans, “except to qualified individuals and institutions,” he said. “The real issue is whether there should be harsh financial penalties attached to the illegal sale of these instruments. Maybe, as with cigarette taxes, we could finance our educational system by taxing zillionaires who want their own brain and body scanners at each of their multiple homes.”

CAN A CONSENSUS BE REACHED?

As for ultimately how to decide on what is ethical and legal regarding the potential uses of imaging technology, Dr. Illes is an advocate of self-regulation through engagement of all parties. “We can bring educators together,” she said. “We can bring neuroethicists together. We can bring neuroimagers and health policy and legal experts together.... We can get a handle on how to move forward in making these services a positive public opportunity, as opposed to one that has, I think, some pretty critical challenges associated with it.”

Added Dr. Gardner: “I am a believer in professional judgment and would prefer that these decisions be made by the medical profession, the educational profession, and, as appropriate, the legal profession. But I am not optimistic that these professions have enough power or will to take strong steps vis-à-vis the abuse of new neurologic (or other medical) technologies.

“When professions fail, so to speak, this is where laws and regulations need to be imposed by the relevant legislative bodies,” Dr. Gardner continued. “And such laws won’t be passed unless there is strong public sentiment. Interestingly, this is a place where the political left and right might come together—the left opposing intrusions on a civil rights basis, the right because of perceived challenges to the religious sanctity of the individual spirit or soul.”

NR

—Colby Stong

Suggested Reading
Farah MJ, Illes J, Cook-Deegan R, et al. Neurocognitive enhancement: what can we do and what should we do? Nat Rev Neurosci. 2004;5:421-425.
Gardner H. Frames of Mind: The Theory of Multiple Intelligences. New York: Basic Books; 1993.
Illes J. Medical imaging: a hub for the new field of neuroethics. Acad Radiol. 2004;11:721-723.
Illes J, Kann D, Karetsky K, et al. Advertising, patient decision making, and self-referral for computed tomographic and magnetic resonance imaging. Arch Intern Med. 2004;164:2415-2419.
Illes J, Rosen AC, Huang L, et al. Ethical consideration of incidental findings on adult brain MRI in research. Neurology. 2004;23:888-890.
Kolata G. Rapid rise and fall for clinics that market scans to patients. New York Times. January 23, 2005:1, 18.

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