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Thursday, January 15, 2004

Session 3: Neuroscience, Neuropsychiatry and Neuroethics: An Overview

Robert Michels, M.D., Walsh McDermott University Professor of Medicine, Cornell University Medical College

CHAIRMAN KASS:  May we get started, please.  This afternoon, we are in for a treat.  The Council is entertaining two sessions on the topic of Neuroscience, Neuropsychiatry, and Neuroethics, taking up for the first time explicitly this particular area of biomedical science, and its possible ethical implications.

Neuroscience, the scientific study of the brain and its activities; neuropsychiatry, the scientifically- based biological approach to healing and relieving disorders and distresses of the psyche.

And neuroethics, and I am not exactly sure that I have this right.  A neologism that is meant to embrace the ethical implications of advances in neuroscience and neuropsychiatry, ranging from the ethical issues connected to technical interventions, such as the use of psychotropic drugs, or deep brain stimulation, to also the implications for human self- understanding on such topics such as the nature of ethical judgment, the character of personal responsibility, the implications for human self- understanding in those areas secondary to the scientific findings of neuroscience.

I don't want to say very much about this.  This is our first venture into this area, though we did touch on some of these matters in the Beyond Therapy Project, where we looked at techniques for affecting memory, mood, and behavior, insofar as they might go beyond the bounds of healing.

But I think it needs a little argument to discover that the studies on the human brain will have powerful things to say about the activities that are central to our humanity and that the human, and ethical, and social implications might very well be profound.

And that since no previous public bioethics body has explored these questions, and we are in a position at least to start thinking about them, we thought that we would invite people to this council meeting to introduce the subject, and to get help, we have chosen two different approaches. 

One, a kind of synoptic overview of this area, and the second a specific area of intense and exciting research interests at the moment.  Before introducing our guests, let's just be clear about our purposes here today.

They are entirely self- educative, and we have no axes to grind.  We are not interested in making recommendations, or regulating, or implying anything wrong about anything that anybody is doing.

We do sense that this is an area of profound importance, and if we are right, we are eager to learn if and how this may be true.  We are very fortunate to have with us today two very distinguished guests. 

First, Robert Michels, who is the Walsh McDermott University Professor of Medicine.  He is also a University Professor of Psychiatry at the Weill Medical College at Cornell University, where he was previously First Chair of Psychiatry, and then Dean of the Medical College.

I have discovered in thinking about this that I have known Bob for almost 35 years when we were early Fellows at the Hastings Center.  He is now on the board there.  Bob was one of the first people in the medical area to recognize the importance of the bioethical issues that were coming, and it is nice to see that unlike me he is still a promising young man.

Our second distinguished guest is Professor Jonathan Cohen, who is a Professor of Psychology, and Director for the Study of Brain, Mind, and Behavior, and the Director of the Program in Neurosciences at Princeton.

And also the Director of the Clinical Cognitive and Neuroscience Lab at the University of Pittsburgh.  He has trained both in medicine and in cognitive psychology, and he is a leader in the study of the emotional brain, mechanisms of decision making, and moral judgment, and cognitive control, and also in neuro- imaging.

The full- blown curriculum vitae are in your folders, and I won't rehearse them further.  Bob Michels has the task of giving us an overview in the first session, and we will take our break, and then we will hear from Dr. Cohen.  Bob, the floor is yours, and welcome to both of you.  Thank you very much for coming.

DR. MICHELS:  As you can see, I am technologically challenged and here under false pretenses.  Leon said that we have known each other for 30 some odd years, and I looked forward to coming, and with the right audience could probably pass myself off as knowing something about neuroscience, but not around the table with Professor Cohen, and Professor Gazzaniga.

And in the right audience, I could even pass myself as knowing something about neuropsychiatry, but not with Profewssor McHugh sitting in the audience.  And I guess that must make me a neuroethicist.  I don't know what that means, but since neither of us knows what it means, maybe that's why I am here, and why I have been invited.

I am afraid that in 45 minutes that you will decide that I am not that either.  I am a physician.  I am a psychiatrist. I am a fascinated observer of neuroscience, and neuro- biobehavior research in my own institution, and neighboring institutions, and in the field.

I used to run a very large mental health service delivery system in an academic medical center, and I was Dean of a Medical School, and responsible for the curriculum to educate lots of doctors, and lots of psychiatrists, and at one time the largest psychiatric training program in the country.

And I have been for years an amateur bioethicist.  Those are tangentially appropriate credentials, but they didn't provide me with any real sense of what I might say that would be of value to you. 

So I decided understanding that you are thinking of embarking on a new area, to rather than be educational, to be provocative, with the hope that my provocations might stimulate you to educate each other and have interesting places to go, or things to do afterwards.

My impression is that the explosion of inquiry in these fields lead to new knowledge, mostly knowledge that from the human point of view means greater precision about things that we only vaguely knew before this new knowledge.  I will come back to that.

And to new power, and the ability to do things, mostly meaning greater specificity, the power equivalent of precision, and the ability to do more specific things than we have been able to do before.

That means in general that what we know and what we can do is not qualitatively different than has been true for thousands of years but it may have qualitative significance. 

The quantitative difference may have qualitative significance, because we know in general that the brain is related to behavior, but when we can tell by examining the living functioning brain whether someone's behavior is similar or different than someone else's behavior, we have a kind of precision to that knowledge that makes a difference or that may make a difference from the point of view of its ethical significance.

And it seems to me that it is those kinds of things that you might want to be interested in.  It seems to me that there is an analogy in other areas of science, and medicine, and knowledge. 

It was always knowable what gender a person was usually at birth.  We now can tell close to conception.  That seems to make a difference for certain kinds of thinking and decisions. 

We always found out eventually whether or not someone had the Huntington's gene if they lived long enough, but now we can tell before they are born, and that seems to make a difference, although it is only earlier and more precise knowledge.

We have always known that there is a general risk for all kinds of diseases, somewhere between zero and a hundred for every one of them, but now we have all kinds of ways of finding out very precisely what that risk is for a given individual.

We have always known that there are things about the brain that relate to personality, and intelligence, and the ability to learn, and to make moral judgments, and to reason, and all kinds of things like that, but we have never been able to tell much very precisely about any given individual, and that makes a difference.

We will probably in the relatively early future be able to make much more precise statements very early in life about an individual's probable predispositions to a level of intelligence, or a type of learning capacity, or a type of learning disability, or a style of personality, or a tendency towards impulsive violence, or a capacity for guilty self- reflection, in a way that we have never been able to do before, except by the crude imprecise judgments that we make on psychological grounds.

Those things are not qualitatively different, but they are quantities that may lead to qualitatively different ethical concerns, and it is those that I will try to at least imply in what I am talking about.

We can't read minds, but we are beginning to be able to read brains, and the reading of a brain has implications for what one might be able to find out if one could read a mind, and that ability gives us knowledge with a precision that we have never had, and possible implications. 

I would add, and I feel that I have an obligation to add this from one of my roles, that all this new knowledge and new technology until now for the most part has had much more impact on bioethical discourse that you people all do than on such mundane things as the care of the sick, or health delivery, or things like that.

For the vast majority of people who are sick and go to see a doctor, cutting edge scientific knowledge about their brains doesn't make any difference at all because we have not figured out a system that will allow the knowledge that we had 10 years ago to have a real impact on their experience.

The limiting factors in the experience of sick people in our current system is that the political, economic, and social aspects of the delivery system, not the scientific knowledge of their brains and bodies, and I don't see a lot of suggestion that that is going to be any different in the next decade or two, or three, I'm sorry to say.

As I said, we anticipate new knowledge, and new power or capacity to intervene somehow or other.  Both of these, the new knowledge and the new capacities, can pertain to the species as a whole, or some huge group, like all members of one of the genders, or everybody with some genotype, or phenotype, or can pertain to a given single individual, and they have somewhat different significance.

Let me start with new knowledge about the species as a whole.  We are learning a lot about the neural substrate of the mind; of thinking, of feeling, and even of the things that you do, of ethical discourse, and moral judgment.

We have always known that there is a neural substrate.  There is nothing new in that, and I think nothing particularly important for this group.  However, what we are learning shapes and refines what we think about mental processes, and what we are learning about the brain begins to have impact, and the way that we think about the mind.

And that is important for what you talk about in this room.  There are facts that are not yet known, but are knowable and soon to be known that are relevant to discussions of such issues as who can understand the consequences of an action, or who can decide not to take an action that they are able to contemplate.

Or who can empathize with the experience of another human being, and feel what they feel, or can't empathize with that experience.  Who can change their tendency to behave as a result of experience, and who won't change as a result of that experience.

The facts that neuroscience will teach us won't answer these questions.  They are intensely human questions, but any dialogue concerning these questions would want to be fully informed about, and will be influenced, and will be enriched by those facts, and will be impoverished if it ignores those facts.

I can imagine, for example, that one of the things that you might want to do is think about what would be the appropriate summary of what we know about neuroscience or will know about neuroscience for a non- scientifically knowledge ethicist. 

What difference does it make to an ethicist, or for that matter a Supreme Court Judge what Drs. Gazzaniga or Cohen know about the way the brain makes decisions about when and whether to act, or not to act, and how the individual responds to social responses to those decisions.

For a specific example, I think our longstanding traditional distinction between cognition and emotion is beginning to fall apart, in part because of new knowledge about the brain.

It is going to lead to challenges to the traditional ways that we value these things and we think about them.  Our neurobiology of cognition is older, but it is increasingly accompanied by a neurobiology of emotion.

And, for example, when I read a fascinating recent publication about memory, and the way that we think about memory, and about changing memory of traumatic events, and what difference it might make, it is written as though memory had a single meaning.  As though there was a memory about an event, rather than multiple memories.  It doesn't recognize that there are different kinds of memory.  It doesn't discuss the fact that an intervention might affect one type of memory differently or even oppositely to the way that it affects another type of memory.

It does not discuss the fact that you might, for example, enhance cognitive memory at the same time that you reduce emotional memory, and in fact it might be inevitable that that would be a consequence.

Now, a discussion of the ethics of altering memory is going to be influenced by a more sophisticated concept of memory, which in- turn is going to be influenced by a more sophisticated understanding of the neurobiology of memory. 

I don't mean certainly that a neurobiologist who studies memory would per se be an expert on the ethical issues related, but I am saying that an ethicist who doesn't know what that is about is seriously disabled for optimal ethical discourse.

Once again, I think these matters are going to be of great interest to the people sitting around the table; to bioethicists, to philosophers, and maybe to the small group of people who aren't bioethicists or philosophers like myself, but who love to read the papers that bioethicists and philosophers write, because they are interesting.

I don't think that they are going to be terribly important to physicians, or patients, or sick people, or people trying to make them well, and to what transpires between them unless they first have been processed through a bioethical dialogue, and their relevance is dissected and explained to that group.

New knowledge about individuals, as opposed to about the species, or huge groups of the species in general.  Here I think the kind of impact that this knowledge will have will be different.  I think this knowledge will be far more important to patients and doctors, although it will be a concern of course also to bioethicists.

But primarily a concern to bioethicists because of the practical transactions between patients and doctors that itwill engender, and the ethical aspects of those transactions that will have to be considered.

I can't read your mind, but if I could read your mind, I would have all kinds of moral dilemmas that you would have to help me with.  Reading your brain isn't the same as reading your mind.  But it is a step toward reading your mind.

And if I can tell by devices not yet, but soon, in existence, whether you are feeling guilty or don't when you are talking about something, what it is that triggers your desire, and what is your favorite type of taste, or passion, or perversion, and what the likelihood it is of you being able to control it, or impulsively indulging it, or somewhere between the two, then I have fascinating knowledge about you.

And I have some very interesting decisions to make about what to do with that knowledge and how to use it.  I never worried about those issues, because I can't tell those things at the moment.

But if I could tell, I would begin to worry, and when I worry, you have a job it seems to me to tell me at least how to worry.  In many ways the capacity to acquire new neurobiologic about individuals is analogous to the recently extensively discussed capacity to acquire new genetic knowledge.

But the neurobiology is far more powerful than the genetics.  The genetics tells us about risk factors, and predispositions for diseases or certain traits, but genes only outline the starting gross structure of the system.

A comprehensive neurobiologic assessment of an individual, or perhaps of a fetus, could in theory reveal much more precise information about that organism's potentials, and capacities, and limitations than a genetic analysis could ever reveal.

It would reveal not only the results of the genes, but also the impact of the experiences that occurred to those genes and how they were integrated.  The brain has many complexities that can't be discovered from an even thorough knowledge of the genes that went into designing that specific brain, but could be assessed or described by direct studies of the brain, and we are beginning to become interested in that.

I will take an extraordinarily crude example.  Scientists in my institution, and I believe former colleagues or current colleagues of Dr. Cohen, have been interested in studying disturbances in the acquisition of language in young children.

And they have been able to observe differences in the neurobiology of language acquisition, the sequence of parts of the brain that are involved in acquiring a language that are different than those that will develop dyslexia, as compared to those who won't develop dyslexia.

Now, that is wonderful, and it offers the opportunity for thinking of interventions that will make a difference, and for assessing their ethicacy, but it also opens up some interesting questions about the kinds of things that we might know about a child who has never seen a word because they have seen it, and what that knowledge is going to mean.

Doctors and patients work with phenotypes, not with genotypes, and mental capacities, temperamental flavors, character structure, are all phenotypes, now assessed all the time very imprecisely, very tentatively, and treated rather poorly, predicted poorly, by clinical methods.

But potentially describable, categorizable, quantifiable, and predictable, by currently unavailable, non- invasive, or traumatic, neurobiologic assessments.

For example, imagine evaluating an infant or every infant in order to determine probable future patterns of intelligence, personality, temperament, and the like, and then prescribing child rearing practices, optimal school curricula, optimal environments, metabotropic glutamate receptor interventions, in order to make sure that you steer that child toward, and then we have to think of how to end the sentence.  Toward what? 

We are not quite sure.  We never had the capacity or power, or the need to worry about it, but with the capacity and power, perhaps we should start to think about what it is that we would steer toward, and who we would steer and who we wouldn't, and what are the advantages of intervening or of not intervening.

And what are the implications of a world in which some choose to intervene and others don't?  As in genetic knowledge, the basic issue is the large part of life will be much less unpredictable than it has always been in the past.

It will be more precisely predictable, amenable to greater control.  From the beginning until a few decades ago, we discovered a child's sex at birth, his intelligence in school, and his character, very gradually if ever.

Genetic biology has moved the timetable forward.  Neuroscience will move it much more forward and make the content much more precise.  This opens up questions about the importance of unknowability to being a person, and that is an issue that I think this group would be interested in.

Does it influence our basic humanity if details of our personality and character are knowable at our birth or shortly thereafter, and then themselves shape the interventions which we learn that we will be determinants of those details.

Would we treat someone differently if we knew their proneness to impulsive violence was so great that they were likely to be dangerous to the community rather than creatively innovative in that community, et cetera, et cetera.

New interventions.  Interventions for the species.  Neuroscience and related technologies not only lead to knowledge, they lead to power.  Interventions that affect the species in general, or large groups of the species, seem somewhat science fictiony to me, but I think they are probable. 

We fluoridate water today to deter tooth decay.  Why not add substances that delay Alzheimer disease, or improve memory in general, or even make people feel better, and reduce the incidents of depression, or make everybody just a little bit happier, less anxious, more connected with others.  Maybe that would even make people more moral. 

Are there moral problems in using neurobiologic interventions that will reset the balance between narcissism and empathy, between selfishness and altruism, and by doing that make us a more moral culture?

Would it be moral to make us more moral, or immoral to make us more moral, or moral to leave us immoral.  Very interesting verbal possibilities here.

Is there a difference between raising a child to be a virtuous adult, using rhetoric and persuasion, and language, and reward, and love, and punishment, which all of us have tried at least with our own children, and notice the frequent failures that occur along the way.

Or resorting to a quick, effective strategy that achieves a more effective result, with less trouble and greater certainty, by skipping some of the intervening steps and changing the balance of motivating systems and emotions that control behavior.

Would the result be the same or would the result be inherently different?  New interventions on individuals.  This is where doctors are comfortable.  This is the medical model.  Find out what a person needs, and do something to make them different, and then they will be happier.

And if you are in a good health care system, you will get paid for doing it.  The doctor and other health professionals does something, physical, pharmacologic, psychologic, to the patient, with the intent of curing disease, preventing disease, and enhancing well- being, or even improving function or pleasure.

We are most comfortable with the classic model.  The patient is sick, and the treatment returns the patient to normal, and it ends the sickness.  And the secondary or side effects of the treatment are minor, but they are negative. 

As we deviate from this model, we begin to get progressively more and more nervous.  The patient isn't sick, but only different.  Maybe short, or fat, or fidgets a lot in school, or gets angry very easily, or feels low a lot of the time.

Or maybe even the patient is normal, but like normal people, would like to be different.  They would like to be prettier, or have a more pleasing shape, or texture to skin, or maybe straight teeth, or perhaps deeper insight into his fantasies and unconscious wishes and desires.

Lots of people want those things, although they are not sick.  The intervention has an effect.  It makes the patient more attractive, or stronger, or a better student, but you can't really say that it makes the patient less sick.  It is not even a patient anymore. 

The intervention may also have secondary effects, but the secondary effects tend to be pleasant or desirable, rather than risky, or dangerous.  They may make the person feel good.  The person might even enjoy the treatment.

I have had a longstanding interest in treatments that are so enjoyable that the public has been concerned about making them available because they will bankrupt the system if everyone swoops down in order to get them.  They are so much fun.

People may seek out the treatment because they like it, rather than tolerate the treatment because they need it.  What kinds of problems would this create? 

What does neurobiology promise in this area of personal health care, as opposed to new knowledge, or social, or public health interventions?  Certainly and probably most obviously newer, and newer, and newer, and better, and better, and better pharmacotherapies of various kinds.  The drugs are getting and will continue to get safer, pleasanter, and more precise in their impact.

As we dissect the newer biology of emotion, we will probably have much more precise interventions that influence emotions, that turn off unpleasant ones, and turn on or substitute more pleasant ones.  We will be able to manipulate the balance.

We now have drugs that stimulate and sedate.  We have had those for hundreds of years.  We have drugs that will go a bit of a way towards stabilizing labile moods, and we can counter depression, and we can provide some pleasant highs.

In time, we will be able to tinker with the set point of one's mood or emotional state, elevating one's average mood, but keeping it within the normal range. 

We are playing with strategies for diminishing the emotional intensity of painful memories, and reducing the risk of post- traumatic stress disorder in the process, making the experiences that have always horrified people somewhat less horrifying when they recall them.

Now, some are horrified by the notion of tinkering, with the natural horror associated with horrifying experiences.  Our newfound ability to observe the brain at work will lead to strategies that will enhance the potency of our psychological interventions.

The longstanding problem with psychological interventions has not been that they are not powerful. They are immensely powerful.  It is their almost total lack of specificity, with very little notion of how they work, and what they do, or what their effect would be on a given individual.

We know what the therapists intends to do, but we don't know what happens to the patient very well.  We know what we say, and we don't know what the patient hears, or what it remembers from what it hears, or what he experiences.

And in spite of our patient's fantasies that we know how to do it, we are pretty bad at reading their minds.  But as we learn to read their brains, we get closer.

When we intervene in the body with probes or catheters, or other instruments, x- ray guidance greatly increases our power to do things with those interventions.

Using neurobiologic techniques to be able to observe and measure the effects of our mental interventions will make a similar difference in our capacity or potency to make a difference. 

I would love to know which of my interpretations are heard by my patients, and which ones stimulate their emotions.  Which ones get them thinking.  Which ones cause them pleasure, and which ones make them angry at me, and make them reject me.

And even though in real time, if I had the ability to monitor my interventions the way that my cardiac catheter team can monitor its interventions, I could be more effective regardless of my goal, but that is a scary phrase to add at the end, because I can imagine people that I wouldn't want to be more effective, because I don't like their goals.

Certainly we would all applaud it if was in the treatment of disease, but the kinds of interventions that I am talking about can be used for all kinds of things; selling soap, electing Presidents, treating disease, et cetera.

In a very primitive experiment in my department, the investigators were able to use fMRI studies to determine whether subjects exposed to hypnosis would be influenced in their subsequent behavior, and then confirm our predictions by observing their behavior.  We can tell without talking to the subject whether they have really been hypnotized or they are just pretending to be hypnotized because we can influence their neurobiology by hypnosis in a way they can't do voluntarily.

And that opens up all kinds of interesting potential possibilities.  What about direct interventions in the brain?  We not only give people drugs, but we can stimulate them, and we can ablate parts of their brain.  We can put in tissues from other organisms or individuals, or parts of themselves.

We can use mechanical means to localize delivery of drugs or active chemical agents.  Here my own sense is that the future is extremely far away.  This may reflect my age and phobias in this area, but I think the risks and fears of people tinkering inside of brains so dwarf any anticipated benefits, except for the treatment of devastating diseases, I don't think we will see much in the near future.

Or edging in from the boundaries, and we stimulate the brain by stimulating the vegas nerve in the neck, rather than entering the cranium, or by using transcranial magnetic stimulation without even touching the individual.  So we are getting there from the outside without touching and that is the beginning certainly.

But so far I have seen nothing that makes me think our potency with these manipulations, or their precision is any greater than other methods that we have had before. 

In brief, I think the new knowledge is going to be far more important than the new interventions that we are going to have that are used clinically or in other ways. 

I think they will influence ethical dialogue in general by modifying and enriching our notions of cognitive and other psychologies so that the nature of the mental life that ethicists talk about will be known with the precision that it has never been known before.

Again, the example.  There isn't such a thing as memory without saying that one of the memories, or one of the categories of memory, and we have to start including that into our thinking about what it means to influence memory.

It will pose new problems for biomedical ethics in the traditional sense through our vastly increased knowledge and predictability about individuals' potentials, capacities, and limitations, in terms of personality, behavior, ability to learn, ability to be modified, et cetera.

Interventions that are developed will continue to be more and more specific, and less and less dangerous, and therefore more and more popular for people who desire them rather than only for people who, quote, need them, because they are sick or seriously disabled.

I think that we will be or will need to discuss the implications of using this knowledge and these interventions to give or fulfill individuals' desires without treating disease or disability. 

And we will begin to worry about the differential availability of them and the possible problems of fairness and social advantage, or disadvantage to different segments of society, or different communities that that will create.  Thank you.


CHAIRMAN KASS:  The floor is open for questions.  Bob, let me start with a couple of things of clarification while my colleagues warm to the task.  You were fairly expansive about our ability to somehow monitor what goes on in the brain, and indeed monitor individuals and screen, but I am just sort of interested in the facts on this. 

Would this require something miniaturizable for — I don't mean for insertion in the brain, but are people going to walk around with imaging devices so that one can check up?  I mean, how is this going to work?

And the second question related to it is that I am also interested not just in the technical ease of this kind of monitoring, but also what you call the predictive value of the information.  Why would certain kinds of screening early on be anything more than, let's say, probablistic?

Could you say something about how good is the prediction, and how are we going to get this kind of massive amount of information about all of these mental things through checking up on brains?

DR. MICHELS:  Let me start with the second, because I might be able to answer it.  Of course it is probablistic.  But there is a difference between our current imprecision of such prediction, and highly precise predictions. 

What if we could after an MRI of a 6- month- old tell you what the range of the future IQ was going to be as fairly reliably predicted from the ratios of various brain measurements?

Certainly if you could identify future geniuses, you would want to exploit that potential, or somebody would, by early schooling.  And if you could identify those who are never going to learn very much, you would want to conserve resources in order to have them available for the first group, et cetera, et cetera, et cetera, or some would argue this.

That is impossible without the technology that allows still probablistic, but more precise than current predictions.  I would say that the chances of the probabilities becoming socially relevant early are for the first time in the history of the species real because of this.

The predictions until now have been made on the basis of correlations with heavily disputed characteristics that are not just to correlate with, like family, class, race, social background, et cetera.

But what if we had real correlations with the biologic potential?  Where do we go from there?  I think that the probabilities will become socially relevant within the foreseeable future. 

Your second question, or your first question — I'm sorry.

CHAIRMAN KASS:  My other question has to do with how we are going to get all this relevant information, this information.

DR. MICHELS:  I raised two different types of situations, but what I am talking about now in theory could be MRI scans with enough precision and enough knowledge about the importance of the various variables that could be done just as we now take core blood from every child born in the New York State to measure certain genetic predispositions to disease.

CHAIRMAN KASS:  Done once?

DR. MICHELS:  Possibly, or maybe done twice, or maybe done five times, or maybe tests that would be challenge tests.  So maybe under observation we would stimulate the infant and see how the brain responded to that stimulation.

But they are foreseeable doable within the range of economic and social possibility.  It might take 20 minutes in the machine, and five stimuli in watching the brain's response to it to get a sense of a pattern that we would note from studies correlated with this probability of future outcome.

CHAIRMAN KASS:  Dr. Cohen, would you like to just join on this?

DR. COHEN:  Yes.  I pretty much concur with everything that Dr. Michel said, but I would add maybe to just the force of his comments the fact that there are technologies that at the moment compliment, but at least in the foreseeable future might begin to replace MRI in certain settings that are much more portable.

Optical imaging, where you actually shine light into the skull and measure the refraction characteristics or the frequency spectral characteristics of the return light to provide another way of measuring blood flow, which is effectively what most forms of functional MRI are measuring now.

And there are attempts to develop extremely portable versions of this. There is a guy at the University of Pennsylvania who has developed what he calls I think — and I think somewhat glibly the Cognitron, which is — I think it is a couple of gram device that you can affix multiple ones of on the scalp, and he has a picture that he shows when he talks, and he says this is Britten Chance of a classroom of Japanese students where he has done a study with this thing in a math class.

And 10 of these devices on each of their heads.  Now, right now the information that that device is giving us is rather imprecise and nowhere close to the kind of information that Dr. Michels is describing.  But I would conjecture that it is at most a matter of time before it comes close.

CHAIRMAN KASS:  Thank you.

DR. COHEN:  With MRI, we are much, much closer to that sort of precision and non- probablistic sort of information.  Studies are getting done now on choice preference behavior that are close to being able to reveal meaningful information about individuals from a single scanned section.

And with regard to what their preference is for, say, Coke versus Pepsi in a double- blind study, where you can look at the brain and figure out what they are going to prefer.  So in some domains I think it is getting remarkably close to the sort of scenario that was described.

CHAIRMAN KASS:  Thank you.  Dan Foster.

DR. FOSTER:  You know, let me just follow up on that, because if you look at the experience from laboratory science, let's say, in molecular biology and so forth, the more we go, the more it gets more complicated.

You know, you used to have a gene, and a messenger RNA, and one protein, and that used to be the dogma; one, one, one, you know.  We now know that is multiplied in dozens of ways.  I mean, you splice the messenger RNA differently, you know, and then you put on different carbohydrates and so forth, and it is much more complicated.

It seems to me that you are talking about events, even with what you just said with shining light in, in the most, I suppose the most complicated organ that we have in the body.  I would find it very difficult to determine what a specific — let me just be crude. 

You light up a PET scan, and you are looking at glucose metabolism, or blood flow, or whatever, which are really when you look at it pretty crude compared to what the neuronal networks and interactions, and if you watch these things grow when you are growing them as the biological people in the brain are doing, it is hard for me to sit here and believe that you are in a meaningful sense going to be able to predict whether — you know, whether somebody's whole neurobiological life — maybe that is right.

But I can't believe that this most sophisticated organ is going to be easier to understand than less sophisticated, but very — you know, things along this line. 

I hope — I don't know if I hope that it is true or not, but it seems to me that there is a huge jump from what we have got right now with functional MRI, and I think you can — and I am sure that you are going to talk about this.

You can tell what — you know, give a thought game, and making a moral decision, and see what part of the brain lights up or something.  But the sort of things that you were talking about Dr. Michels, it seems to me that they are going to be very difficult, because almost always their final common pathways are in memory.

I mean, hearing gives you something different, and you end up in the same place, but writing, or verbal, or visual, how would you — I mean, why are you — I guess what I am saying is why are you — you started off by saying that you don't want to hide things.

But why are you so certain as you seem to be that we are going to be able to do that?  I am just interested.  I am not arguing, but I am just interested.

DR. MICHELS:  As I said, I tend to be provocative.  I am pleased that I have at least in one case succeeded.  I am not certain, but I think this.  The brain is a black box, and it has been a black box forever. 

It is only within the last decade or two that we figured out how to look inside the black box in life, in humans, and we have found that we have knowledge in that box that correlates with socially discernible important variables, an entirely new area.

We have never had this available to us before, and our techniques are growing in potency by leaps and bounds.  I think it is unimaginable that we won't have relevant knowledge that increases significantly the precision of the predictions we have long made on psychological and social grounds.

Those predictions are so important about human life that anything that increases the precision of them is ethically relevant.  My guess is that those increases are moving so fast that they are going to be relevant to every day social decisions about what class to put a kid in, about whether we are — and we are almost at the point now where we can give meaningful advice about what technique to use to teach a dyslexic child based on information that we obtain without talking to the child.

Now, that is pretty startling to me, and not terribly far from deciding whether a kid is going through an adolescent crisis, or is a future probable, highly probable, violent criminal.  Those are morally relevant decisions, and morally significant information about them that we have to decide how to cope with.

And I don't think that those kinds of things are terribly far away.  Again, I back away.  We have experts in the room that can comment.  I am glad you came out on my side on this one. 

CHAIRMAN KASS:  I have Michael Sandel, and then Alfonso. I have got a queue and I think I have noticed everybody that wants in.  Michael, please.

PROF. SANDEL:  Well, this is just two questions of clarification for Professor Cohen.  The functional MRI is an MRI whose purpose is to determine what parts of the brain are functioning when certain experiences — and that scenario with the Japanese school kids in the math class with scanning devices on their brains, that was to determine how they learn the math, or it was to teach them the math?

DR. COHEN:  It was definitely measurement and not intervention. It was an attempt to see in that case the frontal lobes, which were more activated in one case than in another.  A very, very crude study.

I don't want to overdramatize the findings, nor the method, other than to say it answers the question that was asked, which is how portable can we imagine these methods being, and the answer is possibly very portable.

PROF. SANDEL:  If the knowledge of the function of the brain became precise enough could we use such devices to teach the math as well in principle do you think?

DR. COHEN:  Well, no, because these are measurement devices, and they are not producing any signal that influences the brain, but Dr. Michels did refer to one method, transcranial magnetic stimulation, TMS, which is also in principal a very portable device, that can influence the brain, and is in fact already beginning to see some clinical applications.

So it is being used, for example, as a potential alternative.  It is being explored I should say as a potential alternative to electroconvulsive shock therapy.

Where in effect you produce a localized seizure that carries with it possibly much less memory loss and lesser risks than those that are associated with generalized seizures.  So that method is in fact already seeing clinical use, and is also beginning to see perhaps even more extensive use in basic research.  I will say more about that later if people are interested.

DR. MICHELS:  A footnote to Dr. Cohen's comment.  I think it would be immensely — have immense impact on teaching if you could tell by methods such as this when the students have learned what you were teaching them.

If you could tell when the brain pattern shifted, because they got it, and then they were processing it differently than they were before, as an educator, I would find that very, very much powerful in shaping my intervention. 

DR. COHEN:  Can I have a quick response to Dr. Foster's comments before we move on to another question?


DR. COHEN:  Actually, nobody is more sympathetic to the concern in the question that you raised than myself.  I mean, it is my view that neuroscience as a whole has missed the boat on the complexity of the brain, and there are many consequences to that realization that neuroscience has not taken on that I think are absolutely essential, and I will say a word about that in my talk.

You know, appreciating the anomaly of dynamics, and the need for formal theory in a way that we see in every other discipline that confronts such complexity.  So you get on and saying that these methods are not going to unravel the whole thing in the next 5 or 10 years. 

That said, there is no predicting as a scientist or from any other perspective what is going — what knowledge is going to yield the simple description, and what knowledge is going to require more deeper and more complex understanding.

And in every other domain of science some very powerful things have come from some rather simple insights, and then others have required much more sophisticated theories. 

So the extent to which I agree with Dr. Michels is in saying that as we suddenly gain new methods that we didn't have before, and are able to peer inside a box that we couldn't peer inside of before, some things are going to lend themselves very quickly to discovery, and perhaps to simple accounts, and to simple correlations that will have great impact.

Others, perhaps most, no doubt will require much, much deeper understanding, and much longer research programs.  But just as in genetics, you know, knowing the entire code doesn't tell us very much about the makeup of the person in all the rich ways that we think are relevant to their day to day function.

Nevertheless, it allows us to predict some very important things, like whether or not they are going to have Tay Sachs disease, or whether they are going to have Huntington's chorea, or a whole host of other things that have immediate medical impact. 

And I think the scenario is going to be the same in neuroscience.  There is going to be a host of things that are going to be upon us before we knew what hit us that we can predict, and then a whole lot more that is going to take a lot longer to understand.

DR. FOSTER:  Thank you very much.  I would say that I have a sentence that I always say, that I never say never, and I never say all ways in medicine or science.  So, I am not saying never.  I am just making a comment.  Thank you very much for your clarification.

CHAIRMAN KASS:  The queue has now grown, and so let me ask people to be fairly succinct so we can get everybody's questions.

PROF. SANDEL:  You could scan them to see how long their question is going to be before you call on them.

CHAIRMAN KASS:  Actually, I have a simpler method.   Alfonso, please. 

DR. GÓMEZ-LOBO:  I am going to go back to the little Japanese boys, the mathematicians, because I am expressing a perplexity here, and it has to do with the following.  From your explanation, of course, these devices would be measurement devices of the brain activity while engaging in methodical thought.

But of course that will not tell us which of the answers they provide to certain equations which are true and which are false, first of all.  In other words, there is this problem with the mind that we want to know the truth, and from what I hear here, the truth about mathematics, about a mathematical statement, is certainly not going to come from the brain, right?  Okay.  Let me try another one. 

PROF. SANDEL:  Can you say that again with your microphone on?

DR. COHEN:  I don't know.  I mean, I am not entirely sure what you are asking. 

DR. GÓMEZ-LOBO:  Well, that's wonderful, because then I am going to get more time to make my point.  Let me make it in a slightly different form now with Dr. Michels. 

I thought that your description of examining the six months old children to determine whether they were going to be alpha, beta, or gamma children — I mean, I am parodying you know what.

No, it is not the brave new world.  I am parodying Plato's Republic.  You know, you take a look at the children that are born, and if there is gold there, fine, and they go to the upper class, and if there is silver, they go to the gardens, and if there is copper, they go to the merchants, et cetera.

But the problem then would be, well, would this be just, would this be fair, and nothing I think it seems in the brain is going to tell us whether this is just or fair.

In other words the question about the truth of the judgment made on the fairness of that distribution is to be found in another domain.  In the case of math, it is certainly the actual system that determines the truth of a claim of mathematics. 

I just cannot fathom say decidability theorems that Goedel decided by scanners.

DR. COHEN:  Well, it is interesting that you picked Goedel, because Goedel was among the mathematicians that pointed out what the limitations of any particular proof system can prove, and it may be that the most profound impact that the eventual understanding that we have of how the brain works will be on understanding what the actual fabric of our conceptual systems are, and what constrains them.

And although at the moment I don't think we are anywhere close to being able to look to the brain to develop prescriptive principles of ethics or knowledge in general, it is not inconceivable to me that ultimately as we understand how the brain works that we will gain new insights into the very basic or the very bases of what knowledge is.

And I will actually — and that is in part the main focus of the talk that I will give. 

DR. GÓMEZ-LOBO:  All right.  I will wait until you give your talk now.

DR. MICHELS:  Just a very quick response.  Certainly we are not going to know whether it is good or bad to do this based on studying the brain.  The brain doesn't tell us that, but we have never before have been able to make precise predictions very early about what the child's individual capacities are in many areas where those predictions will become available.

We then have not a strategy to use, but an interesting dilemma of what to do with that potential knowledge; discard it, exploit it, expunge it, reveal it.  Those are the things that I think this group is interested in.

CHAIRMAN KASS:  Frank Fukuyama. 

PROF. FUKUYAMA:  Well, thank you.  That was really fascinating.  I just want to ask a factual question that was not clear from your presentation.  You have the brain's genotype, and then you have its phenotype, but then beyond that, it seems to me that you have the actual — you know, what is actually contained in the phenotype, which in an analogy would be software in a computer.

The same hardware can contain different programs towards memory and so forth.  Now, it is not clear to me from what you have said which of those three things are measurable by these external devices.

I can certainly see that you could see something about the genotype, and I presume when you are talking about predicting the capabilities of a developing child that you are looking at the phenotype, and how that might develop in the future based on certain physical characteristics of the brain.

But how much are you saying that you can actually measure things in that third category which have to do with what actually fills the content of a given phenotype?

DR. MICHELS:  I don't think that those categories are adequate for the brain.  The genotype, the genes, present constraints or limits on the structure of the brain.  Much of the structure though is not determined genetically, but is a function of various post- genetic determination because of various environmental conditions or whatever, and experience.

And of course the content is heavily shaped by experience.  The techniques that we are talking about measure the sum of all three.  The content is really part of the phenotype, and the content influences the structure of the brain.

So one's experiences influence the relative size of one's hippocampus and one's amygdala, and the balance between them, and those in turn shape future experience.

PROF. FUKUYAMA:  Okay.  Could I just modify that then.  Does the content actually have to result in a physical modification of the brain for you to be able to measure it, or is there a way of getting at the content directly without — in a case where there is no physical difference?

DR. MICHELS:  To a contemporary neuroscientist, it is impossible for there to be content without some physical modification.  It may be at the molecular level, and it may be at the semantic level, but what does it mean to say that the content is different, but the brains are physically identical?  That would discard science, and speak to some type of spiritual notion.

Every thought is connected with some structural, or functional, or chemical difference in the brain. 

CHAIRMAN KASS:  And I assume that somebody that disagreed with that is simply — has a different structure of his brain?

DR. MICHELS:  I would say momentarily until I talked to him.

CHAIRMAN KASS:  Okay.  Then the question of truth becomes somewhat — it is, I think, what Alfonso was getting at earlier, but let me not intervene.  Mary Ann.  I have got a long list, but let's try to get through everybody before the break.  Mary Ann Glendon, and then Bill Hurlbut.

PROF. GLENDON:  As a non- scientist, I have been debating with myself whether I should even enter this conversation, but it was so interesting.  Your question of what would a society be like if these probabilities became socially relevant. 

And it occurred to me maybe we know a little bit about that already.  I would start with what social scientists know, that in the 1990s, until the 1990s, more than half of the inhabitants of the world lived in small farming or fishing villages of fewer than 2,000 people.

I might be more the only person in this room that grew up in one of those kinds of villages, but there is an intense interest in heredity among farmers, and they just don't apply it to animals.

And when you live in a society that is not very mobile geographically you have a little laboratory, where you see generations and generations.  And I think we already know a little bit about — I mean, certainly they have a lively sense of heredity and probability, but they know that it is just a probability business, and they also have a lively sense of variations, and things that aren't determined.

So what you know is that there are some characteristic advantages and disadvantages, and the disadvantages are the ones that make a lot of us move out of small villages.  You tend to get families — whole families tend to get typecast, and there is — well, I don't have to go into it.

But on the other hand, there is also this sense — you posed the question how would we know what is good about this.  There is this sense of maximizing the opportunities for people to perfect their own gifts, whatever they are.  That would be the other side of the coin.

So I was just wondering if maybe in our highly mobile societies where we have lost that kind of little experimental knowledge that maybe at least in the near term fancy science will get us to the point that agricultural societies that were not very mobile had already been.

CHAIRMAN KASS:  Let me continue down the row.  I have Bill Hurlbut, Gil, Paul, Bill May, and Mike Gazzaniga, and then we will break then.  Anybody who wants to speak after that, we will do it in the next session.  Bill. 

DR HURLBUT:  I wanted to jump back upstream on our conversation a little to Daniel's comment.  I wholly concur with the concern that we not fall into neurologic reductionism and simplistic notions of how things work at the level of behavior.

(Inaudible) seemed to me to be very important because the information as Dr. Cohen has mentioned, the certain things that might correlate, are actually beginning to emerge in the evidence. 

If it is true that there is a long journey between genotype and phenotype, and if you think of the genotype as fundamentally expressing the genes, which are then greatly modified and they kind of play out in these complex patterns interacting with one another, and you think of those as pigments, and you think of the phenotype maybe as the picture that finally is expressed with the pigments of the paints, still what we are doing here now as Dr. Michels has mentioned is that we are further upstream in that process of the patterning out of the person.

And the point is that now we are not looking at something as primordial as the genes.  We are looking at something just a layer or two before expressed behavior.  And there are in fact already at least six papers which now correlate fMRI patterns with the expression of single allelic differences.

There are papers associated with brain derived neurotrophic factors, and better memory, serotonin transporters, anxiety, stress, proclivities toward depression in some genotypes; amygdala and anxiety correlations, and correlations between phenotypic expressions of pain, and of course neuro or dopamine transporters, and some of the work that Dr. Cohen has done between dopamine receptors and phenotype.

These seem to me to be highly relevant in their ethical implications, and so that I just don't end up making a statement, I want to ask you a question.  Do you think that we will get to the point where we will discern these transitions in learning that you mentioned, and also discern the very pharmacologic intervention that provokes them, and get to the point where education is no longer just kids sitting in desks, and trying to concentrate, but actually neuro- enhanced sessions, maybe with short- acting psychotropics; that now it is time for your math drug, and now it is time for your literature drug?

DR. MICHELS:  That sounds scary, but I think the answer is basically yes.  I don't think that it will happen that way.  I think what will happen is the 6- month- old will be scanned and evaluated, and we will find that this is a nice, sweet, wonderful  6- month- old.

You see, that little gyrus there is a little bit twisted, and the balance of neurotransmitters is a little atypical, and kids like that have trouble with spacial learning link.  He will need a boost when he gets to calculus. 

So instead of giving him a drug for learning disability for years, which he doesn't need, or giving him nothing and dooming him to a lacuna in his final capacities, we will know that in that week of lessons a little bit of a push might have minimal side effects and will help him through what his brain is limited for, and he will be happier as a result.  I think that is foreseeable.

CHAIRMAN KASS:  Gil Meilaender, and then Paul.

PROF. MEILAENDER:  I would just like to think with you a little bit about this.  I am not quite sure where or what I am about to think about these, but you had said that the notion that we might have two brains exactly different, or exactly the same, but the choice was different, was sort of inconceivable. 

If you had the two brains, the thing would have to come out, and I found that I don't find that inconceivable at all, but of course I am not a neuroscientist. 

You said what would that mean, and the answer is freedom, and that is what I want to think about a little bit.  What I want to know is whether there is any place in here for chance, or willfulness.

There are fascinating things in Augustine's City of God, where he is thinking about free will, and he talks about the astrologers, and he wants to argue against astrology, and about how he finally uses these examples about how the son of the master and the son of the slave were born under precisely the same astrological signs, but turned out entirely differently.  I am just wondering if there is anything analogous to that in this area, and obviously in much more sophisticated ways.

But if you can tell something about my brain, that I always choose Coke rather than Pepsi, what does always mean?  Is there room for chance, or is there room for willfulness, where I just don't want you to know about that?

And if this doesn't make any sense, then what do we say about freedom?

DR. MICHELS:  A huge question obviously.  First, I would not lump chance and willfulness.  To me, they are opposite.  Willfulness is —

PROF. MEILAENDER:  There are many different ways of breaking the pattern is all that I had in mind.

DR. MICHELS:  But willfulness implies determinism.  It means —

PROF. MEILAENDER:  No, I was thinking of willfulness as something that stands outside the whole system of causes.  It means free will.

DR. MICHELS:  Well, clearly —

CHAIRMAN KASS:  Dostoevsky's Notes From the Underground maybe.

DR. MICHELS:  To a neuroscientist, I think the notion of chance or something outside of the causal system doesn't mean anything.  It does not fit the language and discourse that that community is involved in.

PROF. MEILAENDER:  Is that a scientific point or a philosophical one?

DR. MICHELS:  It is clearly philosophic.  That is not the result of a science.  That is an organizing frame within which the scientist formulates and addresses questions as I understand scientists.  We have a couple in the room. 

CHAIRMAN KASS:  I think his brain is wired differently.

DR. COHEN:  Well, I think on that point that I would take a slightly different stand, and I would distinguish between free will and chance.  I would say within all of science that there is the notion of chance.  I mean, right down to the quantum mechanical level. 

I mean, that is built on the notion of chance, that there is indeterminacy in the physical world is the essential notion in modern physics.  And I think the same is absolutely going to apply at the level of neuroscience, and so is there an opportunity for what we technically call symmetry breaking?

You have two identical brains confronted with slightly different environments, and they may go the same way and they may not.  So, absolutely it is an essential notion, and in fact we formalize it in many of our mathematical models as noise, and it turns out that has important properties well beyond the scope of this discussion.

But just to say that not only is it possible, but it is embraced theoretically in an extremely important concept that there be chance, or randomness, or noise, in the operation of the nervous system.  That is distinct from the notion of free will, where that will comes from some material or plasma that is outside of the physical or material realm.

And there I agree with Dr. Michels.  I say that as a neuroscientist, and not speaking as a metaphysician, or a philosopher, but as a neuroscientist.  It makes no sense for me to talk about any things outside of that realm.

I am willing to be agnostic as to whether or not there is ectoplasm that exists outside of the material world, or some force of nature, or God, or whatever you want to call it, that has influence.

But as a scientist that is not the game that we play.  The game we play is what can we explain in terms of physical cause and material existence.  And from that perspective as a neuroscientist, I don't think it makes much sense to talk about influences that exist outside of the material world, and with regard to neuroscience, the relevant material is the brain.

PROF. MEILAENDER:  Just a sentence?  Your agnosticism though then would have to mean that it might be possible that your predictions could be falsified by something that is outside of the realm that you are working in?

DR. MICHELS:  I think this is going to take us longer to work out than we have, but if you are asking for falsification in a material form, the answer is no.  That is the game of science. 

You give me material evidence and that is perfectly good, and I am going to say it always has to be material evidence and so we are back to the scientific game. 

DR. FOSTER:  But just one sentence then.  You have already talked about the quantum mechanics and everything.  The uncertainty principles apply everywhere.  So in one sense, you can't — it is too much to talk about right now.

But there is inevitably with, whether it is a photon through the Schroedinger's Cat experience and so forth.

CHAIRMAN KASS:  My electrode says that Paul McHugh wants to speak. 

DR. MCHUGH:  Thank you very much, Bob, for that interesting fairy tale.  I have been listening to this fairy tale for so long.  Look, first of all, we are already now working with our understandings of potential, and organizing the environment of children, and probably maybe with some further knowledge of brain structure, we can do it a few years earlier than we do.

As you know in the public school systems of New York City right now, children at age 6 are selected to go to Hunter Grammer School out of the basis of their scores on psychological tests and it works out pretty well. 

The predictions are extremely well, and we are doing it right now, and if you could do it at age four rather than at age six, that might be an advance.  But knowing the gelatinous layer or gelatinous appearance of a six month old brain, having looked at a lot of them, I am quite sure that there are limits to what you are on about.

And it was that that brings me to my question.  You say appropriately that we are going to get more precise, and I want to know where the limits come given that at the moment none of the neuroscientists can tell us anything about how consciousness emerges from this material. 

If you can't tell us how consciousness emerges from this material at all, you can't tell us what makes us see red when we see red.  How do you really think that you are going to do all the things that you tell us you are going to do before you can answer that question? 

I acknowledge what Dr. Cohen says, that there are going to be surprisingly simple things that are going to emerge from this, but that is not the picture that you are depicting for us for our ethical concerns.

You are depicting for us a sense in which we are all powerful and are capable of doing things that this neuroscience is going to do it.  Do you think that there are limits to what you can achieve given that I don't see in the next hundred years that you are going to solve the brain mind problem. 

CHAIRMAN KASS:  As long as you would like.

DR. MICHELS:  A point of personal privilege.  I am delighted that Paul considers me a spinner of fairy tales.  I couldn't imagine a higher status to achieve in the world or in his eyes.

He is conflating the two categories that I talked about.  One is the implications of our new knowledge for our understanding of the species of cognitive psychology, and then indirectly of moral discourse.

I don't know how consciousness emerges from this gelatinous mass, but I do know that it wouldn't be very helpful to me sitting with a patient, or with my 6- month- old granddaughter, to know the answer to that question.

It might be helpful to me to know whether next year I should enroll her for ballet lessons or for learning how to play the violin, or maybe for ice skating.  That would be useful information. 

And I think that is the kind of information that we are going to get from studies of individuals.  We are not going to progress the way consciousness emerges. 

Before that, we are going to learn that memory is complex concept, and that emotional and cognitive records aren't filed in the same cabinet, and that might get us to rethink some of our notions  about the nature of man.

But again that isn't what is going to influence the way that I make decisions about my granddaughter's education, or assign kids to school.  I agree thoroughly with what Paul said.  We make these predictions all the time based on strategies that we have used for a hundred- thousand years.

Within the last 20 years, for the first time, we have an entirely new class of data never before available to us which promises much more precise and specific knowledge on which to make therefore more precise predictions.

They will still be probablistic, and they will still be predictions, but that is a quantal leap that may have qualitative significance in terms of its social implications. 

Partly because that information will be available to some groups and not others; partly because it will raise questions of resource distribution and fairness; partly because it will raise questions of whether or not we want to make decisions based on such information, or only use our traditional sources of information because they are "more natural."

All of those are not new ethical issues.  But this area will make them have a different concrete significance.  I think that Paul is agreeing with that, and so I think it is a very important fairy tale that we would suffer if we ignored.

DR. MCHUGH:  I agree with you up to a point.  The issue that I am trying to raise with you is the issue that Gil is talking about, too.  That is, that we are people of body- mind continuum, and the issue of developing and recognizing that the brain is important, and that particular parts of the brain are important, and particular parts of the brain are in action when we have a thought, and this work is very interesting, and I would agree very important up to a point.

I am concerned that it is being over- hyped, and we are getting so far from what in our promise for what we would deliver that we are trying to scare people  about what our limits are, and all I am saying is that for me, that if you can't tell me how the brain produces this conscious experience at all, and then let me remind everybody that we can't do it at all.

And yet you think that we are going to be in a process of a kind where people would likely to be in a situation where we are putting stuff in the drinking water and reproducing Walker Percy's example in Love in the Ruins.  I just think that is a fairy tale.

CHAIRMAN KASS:  Bill May and Mike Gazzaniga, and we will take a break.

DR. MAY:  You seem to be claiming that there are proffering a fairy tale, but scaring people with a nightmare.  So far we have talked about the potentiality of this with medical interventions, and then we got into the discussion of education.

But I couldn't help but think about this potential for personal relationships.  I mean, there is nothing more daunting for a young man to declare his love, and it exposes him to extreme vulnerability, potential humiliation, and awkwardness and so forth.

But if I could get a hold of her black box, then think what that would do, and embolding me in overtures, and of course from her side, there might be the feeling that transparency is not all that good a thing, and one would retreat to the ancient wisdom women have of the importance of veiling, and the importance of that in human affairs.  It is a frivolous comment, but it comes towards the end of this session.

CHAIRMAN KASS:  This is an argument for ignorance or for a certain kind of ignorance.

DR. MICHELS:  A quick one- liner, Leon.  In the Hasidic community in New York City, you don't go out on a date without first checking the genome of your potential partner for recessive genes that might cause trouble.

It probably will be at least 5 or 6 years before they will add an MRI to the genome before that date. 

CHAIRMAN KASS:  Looking for what, rabbis?

DR. MICHELS:  For fittedness that will survive, rather than lead to conflict that will disrupt the family.

CHAIRMAN KASS:  Mike Gazzaniga.  He is going to clear this up.

DR. GAZZANIGA:  Welcome to neuroscience everybody.  So, Bob, your talk takes me back to Cornell and many grand rounds and so forth, and I can of hear a couple of things from your talks.  You have always had sort of a love- hate relationship with science.

So let me see if I have this right, and you correct me if I am wrong, because I think you can offer us a possible insight here.  As I remember, you came out of the psychoanalytic tradition, but you were every scientifically fascinated, and you learned, and you loved to talk about it.

And then you studied for years people who were severely mentally disordered, and schizophrenia, Tourette's and a bunch of diseases, and with manic- depressives, and let's take one for example, schizophrenia, and along comes dopaminergic hypothesis, or it clears up what the hell is going on here.

And there is a solid biopsychiatry brainstorm.  And people take the appropriate drugs, and they feel better, and they behave better, and so forth, but nowhere in there was there any understanding of why they thought they were the King of Siam, you know?

I mean, the person was sick, this dopaminergic problem or whatever which one, a neurotransmitter problem or whatever.  Yes, it fixes the brain, but it doesn't explain why we have been dealing with this patient for years.

Now, that revolution sort of puts psychoanalysis on the junk heap of ideas for most of us, and you lived through that.  And I am trying to get at why — I hear that you are fascinated with neuroscience, but you are also quite clear that it has severe limitations on what it can explain, because you know this fact.

You know that neuropsychiatry didn't answer or ever answer that question.  They just moved on.  They didn't know why these people had all these crazy thoughts.  They can just fix their brain chemistry.

Now having lived through that, and having had to rethink — I assume you had to rethink all those things in your mind, can you apply the principles that you learned from that to what this problem is about our increasing knowledge of neuroscience, and what it may mean for normal human cognition?  Does that make any sense to you, that question?

DR. MICHELS:  I am not sure, Mike.  I am today a practicing psychoanalyst.  I never left that.  I was a scientist, a laboratory scientist, before that, and not after that, and so I am not exactly in the history that you outlined.

But I certainly have had a life- long interest in both.  I have no doubt that there will be unanswered questions at any point along the way, and I have no doubt that our traditional fascination with symbols, and meaning, and extra personal socially determined communication is part of our notion of being.

And all that is important in making one human isn't within your brain or your skin, because it has to do with things like language that certainly can't be understood within a single nervous system.

But I think — my view is that the neuroscientific explosion of the last few decades has opened a black box.  We only have glimpses in the box, but we never were able to open it before, and that new knowledge is trivial compared to what is unknown, but immense to what was known, and it is going to make some differences.

CHAIRMAN KASS:  Before the break, might I just clarify one point, Bob.  I take it that you think — rather than think about the actual interventions, you think that the most important first set of topics that we should be thinking about are the implications of a new kind of probablistic, but nonetheless predictive, and more specifically predictive knowledge for thinking about the future, especially of children?  Would that be a fair —

DR. MICHELS:  No, I will go back.  I divided my thought into four parts.  I think the first thing that I would be interested in is the implications of this new knowledge for your view of man.  The lessons of modern cognitive psychology for your discussions of moral psychology.

The second part would be the implications of knowledge about individuals, analogous to genetic knowledge, but far more important and further — and I forget if it is downstream or upstream, but further or closer to the output that we are clinically interested in.

I think interventions are much further down the pike and much less important, and much weaker, and probably in general will be starting as most interventions do, well within the current medical model, and I think that many of the issues of intervention you have already discussed, and they are not new ethical issues, because the intervention happens to be above the neck rather than below the neck.

CHAIRMAN KASS:  Thank you very much.  I thank you all.  We will take 15 minutes, and we will look forward to Dr. Cohen's presentation.

(Whereupon, at 3:33 p.m., the meeting was recessed, and resumed at 3:54 p.m.)

  - The President's Council on Bioethics -  
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