FRIDAY, June 25, 2004
Session 5: Neuroscience, Brain, and Behavior IV:
Brain Imaging (Case Study)
Staff Working Paper, "Neuroimaging and Antisocial
Personality Disorder Case Study"
Today we bring forth two areas, none of them burning questions
at the moment, but things visible already here and on the
horizon, two areas that are fraught with some serious ethical
questions, one having to do with the knowledge gained from
neuroimaging, the other the uses of brain stimulation and
the treatment of psychological and behavioral disorder, and
we've divided the morning sessions exactly along those
lines, one having to do with the ethical questions arising
from the acquisition of new information about the brain and
new kinds of knowledge about the brain through neuroimaging
and the other questions having to do with the possibilities
of intervention in relation to behavioral disorder.
I think that we start from — just to speak in a very
crude way, I think a lot of public interest in this topic
has to do with the recognition that working on the brain one
is somehow working on the mind, working on the person, or
working on the soul, and that there are large philosophical
questions that surface here from time to time, but as Dan
Foster pointed out, I think, the last time, this is ancient
conundrum, and this Council is not going to settle that kind
But whatever might be the ultimate truth about the connection
between the brain, its activities, and things called person,
mind or soul, certainly in various practical situations people
will wonder about whether the brain is different and whether
approaches to various human phenomena through the brain raise
different kinds of questions.
How would the biological approach to behavioral problems
or questions having to do with moral content differ from biological
approaches to diabetes, which is a non-brain matter, or biological
approaches to those brain matters known as dementia and dyslexia,
to dysfunctions of cognition or Parkinson's disease or
epilepsy, permanent and episodic disorders of motor function?
Are there other kinds of brain disorders or brain abnormalities
that would explain aberrant behavior? And if so, does that
open the way for direct and interventive treatment for aberrant
behavior, not through counseling, moral exhortation, not through
pharmacology even, but through direct actions on the brain?
I think these are the kinds of questions.
To get this conversation going, the staff has prepared by
modifying a case study that was first presented at a conference
sponsored by the Lasker Foundation, a case study that would
enable us to think about the ethical questions raised by gaining
new kinds of knowledge of a particular behavioral disorder.
And here the questions have to do with the use of knowledge
to identify and diagnose the condition, the use of that kind
of knowledge to predict possible future behavior, use of that
knowledge to control the propensity for such behavior by recommending
various kinds of intervention and monitoring its efficacy,
and finally, should that predicted behavior occur, to explain
it and perhaps excuse it should it be brought forth as a ground
of moral and legal culpability.
And so keeping in mind, I think, the differences between
interventions and knowledge having to do with cognitive dysfunction,
interventions having to do and knowledge having to do with
motor disorders, we've produced a case that purports to
show neurological correlates of abnormal behavior, in this
case anti-social personality disorder.
I think all of you have read the case. This is a young
man given to bouts of uncontrollable rage. Psychiatric work-ups
suggest that he might fit the criteria for antisocial personality
disorder, as described in the DSM.
Functional neuroimaging using simulated films reveal —
and the case study assumes that there has been enough study
done on this to show that this kind of correlation is at least
reliable; that there is as expected high activity in the amygdala,
unusual and abnormal activity in the orbital frontal cortex,
thought to be an area that has something to do with the control
of anger and other behavior.
There are lots of technical questions that we could raise
about the case and we could raise side ethical questions about
the legitimacy of producing simulated pictures and simulated
cases involving the family pictures and the like, but I think
we should try for our purposes to focus on the questions that
have been posed by the staff in the working paper, and these
questions have something to do with the reliance on this kind
of information in making a kind of diagnosis, questions having
to do with what patients should be told and whether patients
are under an obligation to accept interventive treatment on
the basis of this.
And finally whether such people would be held morally and
legally responsible for acts of violence down the road following
the availability of this kind of knowledge.
Is that okay? I would like to try in the discussion to
keep us talking about one question at a time, and I'll
try to move us through the sequence of questions.
Let me begin with a question on page 5. It's very clear
that the imaging is fairly crude and is nowhere near offering
a causal explanation of these matters, but let's say you
do have these studies showing a kind of high degree of correlation
between these patterns and people who have been given this
diagnosis. Just as a general matter, what do we think about
relying on neuroimaging to assess antisocial personality disorder?
Does this strike you as different from relying on it to assess
dyslexia or dementia or is this simply a similar case?
Mike, that's why you're here.
DR. GAZZANIGA: Finally, I found out.
DR. GAZZANIGA: The problem is that many
of these braining imaging studies are averages of several
patients, and the brains are averaged, ten, 12, 15, 20, 50
patients, and you get this virtual image of averaged brain
areas active during a particular kind of stimulation, cognitive
stimulation. The problem is if you go back to the individual
scans, you will see wide variation in the part of the brain
that's activated, and moreover, that is a reliable pattern
because you then take a particular subject back into the scanner
six months later and show him the same set of pictures, and
a similar pattern is established.
So I think if you look at a particular patient's image,
you might find a pattern that was consistent with some idealized
view of what structures are involved in a disease, but in
any court of law, any lawyer would be quick to point out that
that is a pattern that is consistent, but certainly you couldn't
claim it was causal because the next patient would have a
completely different kind of pattern, and consistent within
the next patient, but not like the first patient.
So you're going to have all of this wide variety of
patterns, and therefore I think to seize upon one and say,
"Look. Those are the pixels that are responsible for
this particular kind of behavior, I just think it's going
to be a hard time to establish that in a court of law.
CHAIRMAN KASS: Well, if we don't
talk about the law first, let's simply ask, and people
have done and I think we have referenced here studies that
have done very recently, published studies on dyslexia in
which in individual cases a similar kind of pattern has been
shown compared to a control group, an abnormal neuroimaging
pattern, and that this pattern has been reversed as a result
of successful interventions and an improvement of reading.
The case study assumes that similar kinds of patterns provoked
by patient specific stimulation produces some reliable difference
between the people the psychiatrist say have this disorder
and a normal control group, and the question is, leaving the
courts of it for now, but simply thinking about how we go
about diagnosing people who have various behavioral disorders,
are there any issues connected with just using this as a mode
of identifying people with difficulties?
Doesn't the fact that we've got an antisocial personality
disorder rather than, let's say, dyslexia or epilepsy
raise any different kinds of questions here or is this just
now we're getting more sophisticated? Instead of having
DSM, we now can move to some kind of imaging that will give
us the behavioral diagnoses on which we should then start
That is, I think, the first question. Paul, what would
DR. McHUGH: Well, first of all, it's
important to know that even the words "antisocial personality
disorder" don't represent, despite the fact that
there is lists of category or criteria you've included
here, don't represent a pure and clear category. Remember
DSM-IV and DSM-III should be looked at like a naturalist field
guide, like, for example, Roger Peterson's Field
Guide to the Birds. It's important to have that because
we couldn't ever agree about what's out there.
But just as ornithology doesn't depend on the Field Guide alone
for its progress, but begins to employ concepts of evolutionary
pressures, environmental niches, ultimately responses, and begins
to see which ones of these so-called species are really independent
of one another, and which ones are really fundamentally blurred
into one another, there's an argument, for example, even believe
it or not about the Baltimore oriole, you know, whether it really
exists as something special.
CHAIRMAN KASS: Fifth place.
DR. McHUGH: Yeah. Now, the DSM-IV and
DSM-III were very necessary at a particular stage in psychiatric
scientific evolution. We had to at least know what we were
calling — what the words we were using were going to
be across the nation. Once again, you had to tell the difference
between a yellow warbler and a Prothonotary warbler even though
some people might think that those distinctions weren't
Now, when it comes to the so-called Axis II groups in DSM-III
and IV, which include the compulsive personality, the narcissistic
personality, the antisocial personality, those are to be looked
at not as separate categories, such as you'd look at dementia, as
clear, cookie-cutter-like replicas of patterns, from patient to
patient, but should be looked at as tendencies, issues of themes
within the life of the person that they have more or less of, much
in the same way as you look at mental retardation.
So when you come to something like antisocial personality,
what you're saying is this individual has a temperament
in which he or she is more emotionally responsive to the situation
at the moment and less likely to feel for the other person
on the other side, but it's not an absolute, and the decision
as to where you say this person meets the criteria or this
person just has antisocial qualities is always argued.
Should you say somebody has an IQ of 80 has mental retardation
or they have to have two standard deviations from the mean
to have it, like 70?
I'm sorry, gang, to carry you into this long thing,
but to some extent getting to the heart of this, the question
you're asking, really does depend upon what you're
trying to explain. If you have a clear faculty loss, like
the inability to read or the inability to see, then aspects
of finding something relatively clear cut in the brain is
probably more likely than when you're saying, well, this
person has a tendency to do this. Maybe he has a strong tendency,
but would you necessarily turn to the brain area to get the
diagnosis rather than continue in the psychological realm?
This is a long way around to say that before we can use
the brain pictures to take the place of the psychological
elements, we've got to be absolutely sure about what psychological
elements and what fixed psychological elements we're trying
Now, I believe with Steven Rose that the best way to look
at the emerging neuroscience and its linkages to the psychological
realm is to see it like the Rosetta stone, that we have several
languages. One language, you know, we've got the hieroglyphics
and the Demotic Greek and things of that sort, but the same
message is in each of the languages, and we don't know
the translation rules from one language to another.
Although we can perhaps expect that we'll find how to
do them, we'll probably also expect to find the same questions
get asked at this level will get asked at that level.
Now, let me just tell you what the question is about, the
antisocial personality, and even our patient here when you
show them something and they explode with emotion. The emotion
may or may not express itself in behaviors that you and I
find reprehensible, like striking out at somebody or hitting
And the psychiatrist again and again at the level of antisocial
personality are faced with people who say, "I couldn't
help it, Doc. I couldn't help it. I couldn't."
And we always, "Well, we don't know the difference
between whether you couldn't help it or you wouldn't
help it. You punched that guy."
"Well, I couldn't help it. He made me so angry,
and you know, Doc, I'm just that kind of fellow. I have
a hair trigger, and I go off quickly."
And then somebody will say, "Well, you've got to
understand him. That's the way it is."
And I say, "Well, we're happy to try to do what
we can," but the real question is whether the society
should have something to say in this, too, not just us.
Finally, some wise psychiatrist will say to the person or
to us that, "Well, look, if there's a policeman standing
at his side, would he still punch him?"
And then the answer always is, "No, he wouldn't."
Okay. Well, yes, he has intense emotions. Yes, his emotions
explode quickly when he's thwarted, but certain additions
to the situation would change whether we would express it
one way or another. Then the treatment becomes how can we
put a figurative policeman at his side all the time.
And somebody says, "Well, you know, you can't."
Well, then maybe you have to do something with him such
that he begins to see that that's there for him. Now,
I don't think cutting his brain is going to do it, but
other forms of restriction of his freedom and ultimately getting
him to see that there are real consequences that he can lead
to control himself.
So ultimately it comes back to the question can you replace
yet the language of brain with the language of psychology.
I say we had better know the language of psychology if you're
trying to do that. I do believe you will find at the level
of the brain much the same things as you will find at the
level of psychology, although probably at psychology you will
add more things, more appropriate things that come from a
culture and our understanding of each other.
That's a long way around to answering your question,
Leon. Can we —
CHAIRMAN KASS: You answered them all,
DR. McHUGH: Yeah.
DR. McHUGH: But, you know, I defer to
my friend Michael Gazzaniga here because I might be —
or Ben — I may be still at sea as I'm trying to
understand the Rosetta stone, as it were. We have a richer
vocabulary at the level of psychology, even though it's
still problematic in our categorization and our diagnosis
than we have at the level of — at the step-down, the
Demotic Greek, if you would, with neuroscience, but the neuroscience
is coming on and bringing wonderful things to bear.
I don't think it's going to really change our moral
attitude towards people psychologically in the realm of social
personality. It's certainly going to change and let us
understand a lot more perhaps about the dementias, things
of that sort, where faculties are lost.
CHAIRMAN KASS: Michael, to this?
PROF. SANDEL: This is really to put a
question to Ben and Michael and Paul, and to maybe just begin
by not asking the big questions about moral responsibility,
but to start at a simpler level and to clear away the uncertainties
about the science just to clarify the question.
Suppose the brain imaging became sophisticated enough so
that for every psychological syndrome that might take someone
to Paul's office, you could put that person in an imaging
machine and maybe show them the video or whatever it would
be, and you could find a certain place where their brain,
the pixels lit up, and that you could identify that with some
regularity so that you could get a reliable correlation between
some event in the brain and the tendency to or the inability
to control anger, or whatever the syndrome would be.
Suppose you could do that.
CHAIRMAN KASS: That's the assumption
of the case, in fact, the exact assumption in the case.
PROF. SANDEL: And here's my simple
question, even before we get to moral responsibility and what
society should do. Would that be interesting to you? And
if it would be interesting — put aside even whether
we have some intervention that can go in and fix that thing.
Put that even aside.
But would it be interesting? And I think it would be interesting.
DR. CARSON: Well, it actually gets at
the root of a continuum here because if you go back many years
ago, you know, people may act in an abnormal way. We didn't
have all of the imaging modalities, but sometimes, you know,
maybe there's a meningioma going through their skull and
we could see that.
And then later on we got to the point where we had plain
X-rays and we began to see more and we began to make more
assumptions, and then we had CAT scans and we could see even
There was a time when people with epilepsy were thought
to be crazy or demon possessed or having some kind of behavioral
disorder. Certain types of epilepsy, then we began to do
CT scans and we could see the medial portion of the temporal
lobe was small, was sclerotic, and we started diagnosing mesial
temporal sclerosis, and then we found out if we went in and
we resected that the seizures would go away.
PROF. SANDEL: By the way, could I ask
you did that lay to rest the explanation that they were possessed
by a demon or not necessarily?
DR. CARSON: Yes, it did.
PROF. SANDEL: Why did it? Why did it?
DR. CARSON: Well, unless demons caused
mesial temporal sclerosis.
PROF. SANDEL: Well?
DR. CARSON: Well, maybe they do. I don't
know. So it hasn't definitely laid it to rest, but at
least we have an explanation now.
PROF. SANDEL: Well, maybe we have two
explanations. Why do we assume that one displaces the other?
That's my puzzle.
DR. CARSON: But let me continue. But
let me continue with the continuum.
PROF. SANDEL: Right.
DR. CARSON: Because then we developed
MRIs, and we could see even more and we began to make even
more associations. We began to look at people's hypothalamus
and saying, you know, homosexuals have different shape and
size hypothalami, and things like that.
And then functional MRI. We began to look at things even
at a cellular level and pretty soon at a molecular level and
pretty soon at a subatomic level.
There's no question that we will begin to find more
and more things that are wrong as we become more and more
sophisticated, and I guess the real question becomes what
do we do with that information because as we find these things,
as we did with temporal lobe, medial temporal sclerosis, we
were able to accurately correlate them, and we were able to
do accurate intervention, and we are able at an 80 percent
level to cure that disease process.
So I actually believe as we apply science to these observations
and are objective, we will, in fact, be able to change things.
Now, you —
PROF. SANDEL: Could I press my earlier
DR. CARSON: Okay.
PROF. SANDEL: Let's say we've
got this whole explanation. The person is possessed by a
demon. Then we discover another explanation. There is this
thing that you've described in the brain. Why do we tend
to think and is it right to think that the new explanation
is inconsistent with —
DR. CARSON: supersedes.
PROF. SANDEL: — or supersedes
the other one? Why is that?
DR. CARSON: I'll defer.
DR. GAZZANIGA: It is absolutely prejudiced
against demons, you know. It's pejorative in every sense.
But you know, the real problem with the example is that neuroscientists
would flip through hoops if they actually could find a pixel
illuminated in the brain that caused a set of behaviors in
an absolute ironclad way. We're just not there.
And the real fact of the matter is that you take any clinical
group, whether they be schizophrenics, whether they be people
with horrible frontal lesions and what have you, and where
because of their disease state, they are told that they are
exculpable for a particular behavior because they had a violent
act or something like that.
The problem is that their rate of violence with this disease
is no greater than the rate of violence in the normal population
for almost all of these examples you read about time and time
and time again.
Now, you can take the case of schizophrenia. The rate of
violence isn't higher than in the normal population, but
the jails are full of more schizophrenics. How could that
be? There must be something.
Well, they're full of more schizophrenics because of
drug abuse, not because of their violent behavior. And the
orbital frontal lesions are the same. You're supposed
to get release from inhibition and you tend to engage in more
violent behavior, but the wards are full of people with orbital
frontal lesions that don't do that, and so there's
this problem that always captures you that these oversimplified
models of cause and effect of the lesion, therefore the behavior
are of interest, and they're certainly tantalizing, but
they're not — it's just not a set piece, and
so to get to this idealized case, there's always other
reality in the way that whole thing —
CHAIRMAN KASS: But I'm sort of puzzled.
Paul begins by saying, "Look. This is just a list of
symptoms." It's kind of an empirical thing to sort
of know what the words mean, and you could say, by the way,
dyslexia is just simply a name. It's not a disease.
It simply means trouble reading.
If it turns out that you find, for example, not knowing
causation yet, but certain kinds of unique patterns on imaging
that correlate with difficulty in reading, let's say,
in 80 percent of the dyslexic cases, I would think that you
know you now begin to think you have some kind of organic
foundation for these kinds of cognitive disturbances.
Similarly, if you've got a group of people that you've
been classifying for years on this symptomatological basis
and the neuroscientists now say, look, in 97 percent of these
cases — I'm not talking about causation —
but there is an imaging picture which seems to correlate with
this and not with other things, and never mind that there
might be other kinds of violent people who act out for different
I would like to think that one would say, "Look. This
helps us. This helps us identify. This helps us diagnose.
This helps us point us in the direction of what the underlying
foundation of this, even if we don't yet know cause."
And we're not talking about exculpation. We're
simply talking about getting a new appreciation that this
is something which is brain related.
PROF. SANDEL: Why do you say, by the
way, underlying foundation? Why don't you just say a
description from another point of view that turns out to be
accurate? Why are you privileging it by that language of
CHAIRMAN KASS: Because I —
PROF. SANDEL: You're sounding here
like Steve Pinker.
CHAIRMAN KASS: Well, this is the question.
Don't you think that the discovery of the presence of
scar tissue in the brain at places or tumors in the brain
in the places you'd expect when you see epileptic seizures
is a better explanation than demonic possession? Really.
PROF. SANDEL: Well, I think that's
a practical question.
CHAIRMAN KASS: No, no, no. I think it's .-
PROF. SANDEL: No, I don't think it's
— it's better if it turns out it provides ways of
treating the problem that wouldn't have occurred to us
otherwise, but to take the example of the dyslexia and the
inability to read and you find some correlations in the brain,
that suggests two possibilities for treatment. One is it
might be if you could intervene in the brain you could change
the ability to read, or if you teach the person to read, you
might find when you do the next scan that those physical characteristics
will have changed.
So it's a practical question whether we, given the two
descriptions can find practical interventions from one direction
or from another direction.
So which explanation is better? I wouldn't say one
is more foundational a priori. I would say the better explanation
is the one that helps us devise a way of intervening that's
effective, but I wouldn't say necessarily that because
we find a physical correlate that the best intervention always
will be the physical one.
CHAIRMAN KASS: We're not talking
about the intervention yet.
PROF. SANDEL: But that's the only
test of better explanation here.
PROF. MEILAENDER: Could I just ask a
question here? I'm not unsympathetic to the position
you're pressing, Michael, but it seems a little bit less
persuasive to me when I think of the case of dementia.
Would you try to run that argument through in that case?
Do you think it will work as well?
The dyslexia one isn't bad. How about dementia?
PROF. SANDEL: I know nothing whatsoever
about it. I meant that would qualify me to answer, but I
would say what I would look for to try to fit an account that
would match the one here we would have to know more about
the reflexive character of the understanding. So the interesting
thing to explore, if you want to work from both ends, obviously
we would look to try to intervene at the purely physical level,
but we would also, I think, want to experiment and see whether
making the person aware of the new description would in some
ways open up possibilities of using that reflexive understanding
to find ways of intervening.
So I would try from both directions. And I don't know
enough about it to know what would succeed or if either would
DR. McHUGH: I'd like to jump in there
because this is the key to that argument we had before with
Michael or with Bob Michaels when I said this approach to
the brain-mind issue was a fairy tale.
I said, and I'm with Michael Sandel on this, that we
don't know how the brain produces the mind and, therefore,
we don't know how the mind affects the brain. We do know
that you can't have a mind without a brain, but we also
know that things which happen in the mind will affect the
brain, just like things which will happen in the brain will
affect the mind.
Now, the brain is an organ like any other. You can expect
it to suffer disease and damage and have that reflected in
the mind, but the mind is also an active agent that can affect
the brain in every kind of way that we know, and our problem
always is this one. We don't want to buy into the fairy
tale that as we know the brain, we are ultimately going to
see absolutely new things in the mind.
I think it works both ways, bottom up, top down. You've
got to find out which way is the most effective way to illuminate
the problem, predict the future, and intervene properly.
Sometimes it works one way and the other.
CHAIRMAN KASS: We agreed we were not
going to settle the large philosophical question that .-
PROF. SANDEL: I think we just have.
CHAIRMAN KASS: But as a psychiatrist,
are you indifferent to discovering brain correlations that
would give you an increased sense of confidence that you're
dealing with — that you have somehow correctly identified
a certain kind of problem?
In other words, are you indifferent to learning about the
brains of your disturbed patients?
DR. McHUGH: Absolutely not. No, I'm
very interested in learning. I want to learn all I can about
it, just like I want to know the Demotic Greek to understand
the hieroglyphics and the hieroglyphics vise versa. Without
that, Champollion wouldn't have understood this. I'm
very interested in the fact that the reading brain is correlated
with the reading mind and vice versa.
But I don't want to privilege one over the other. I
don't want to go so far as to think that I'm going
to introduce demons back in because we've gotten into
a lot of trouble. The reason that we don't do the demons
is, you know, we got into witch burning that way and all kinds
But, on the other hand, I don't want to give up the
fact that the human mind, in particular, is a marvelously
active agent that relates to the brain in ways that are totally
mysterious to us. We don't have a clue how it does it.
And just getting one language doesn't immediately let
you know how it links.
PROF. SANDEL: I agree entirely with what
Paul has said, but take the case we have here in the scenario.
If the guy went into the MRI, saw the video, had the scan,
he presumably would be interested. You or I, suppose we were
in that situation, wouldn't we be interested to know,
well, how did it come out? We'd like to have had that
scan. We'd like to see the scan.
It wouldn't be just the doctor reading the scan, figuring
out, well, can I intervene and tweak it, and then if the doctor
explained to us, well, actually this is the event in your
brain that fired, that lit up when you saw that video. Here's
a possible explanation of the link between the two, and you
would get into a discussion, an interpretation with the patient
about that. Then that would be interesting and potentially
a source of intervention.
So there might be a continuity between the brain imaging
and Paul's line of work. You would actually use that
data as an ingredient and an interpretation that the patient
would share and maybe you could work something. Maybe it
would lead to some deeper understanding that could liberate
him from the grip of this anger mechanism.
PROF. MEILAENDER: Just a quick comment.
As I said, I agree in large measure with the direction. The
two-way movement Paul is describing makes sense to me.
I have to say though, and again only within the limits of
my own knowledge which are considerable, that in the case
of dementia language like organic foundation makes more sense
to me, and it's harder for me to imagine what the form
of intervention at the behavioral level would be that might
actually — you know, so that I think the dementia case
is a harder one for the line that Paul has been pushing.
The dyslexia or the behavioral disorder, I find it actually
pretty persuasive, but I'm less sure that organic foundation
doesn't look to me as if it works in a dementia case.
CHAIRMAN KASS: Alfonso.
DR. GÓMEZ-LOBO: First, with regard
to the demons, I had a sense of de javu because the matter
was vigorously discussed in Greece in the Fifth Century, B.C.
In fact, there is a treatise by Hippocrates on the same disease.
And I won't repeat the arguments, but basically what
happens is that in the naturalistic interpretation, you have
a number of criteria of consistency, prediction, et cetera,
that you don't have with the demons. The demons are very
hard to fasten upon, and actually it's, I would say, that
little treatise together with the treatise on ancient medicine
that is the foundation for medicine even today. Physicians
look for natural causes. They don't look for demons in
But I don't want to discuss that. I would like to add
to some really questions or maybe a slight countersuggestion,
and it's this. When Bob Michaels was here, he said we
can read brains, but we cannot read minds. I don't know
if you remember that remark.
And my first reaction was, gee, this is fascinating, but
then when I went home I started thinking, well, is that true.
DR. McHUGH: The answer is no.
DR. GÓMEZ-LOBO: Okay, but that's
exactly the point I want to get to. If that's wrong,
then the Rosetta stone analogy is also wrong, and the reason
is this, is that from what I've seen here, what a neurologist
does is to observe and observe phenomena, and everything that
Mike tells us is that, of course, we observe lighting up and
functioning of neurons, et cetera, et cetera.
Now, the process of reading is a symbolic process. To read
you have to take, for instance a physical reality, a sign,
and interpret it as pointing to something else, and any reading
is symbolic. For instance, I cannot read Chinese because
I don't understand the Chinese symbols. I could write,
you know, Spanish with a Greek alphabet, for instance. It's
perfectly possible because then I can understand the symbols.
So the assumption of the Rosetta stone, of course was that
you had the same text in three different sets of symbols,
and that's why it allowed Champollion to decipher.
The problem we're facing here is that when we talk about
correlation, we're talking about correlating things or
phenomena that have drastically different properties. Lighting
up is one thing. Choosing to take revenge on someone is a
symbolic action. You cannot understand it by sheer observation.
Even if you had, which Mike Gazzaniga tells us we don't,
but even if we had a perfect correlation, we would still be
lacking a key understanding of what's going on at the
level of the mind.
Now, of course, I wouldn't doubt for a second that the
brain is a I don't know whether you'd call it condition
or I don't want to commit myself on that, but it's
certainly the case that it's an organ that is intimately
connected to all of these functions.
My only word of caution here is that any effort to correlate
the two has to take into consideration the fact that these
two things have drastically different properties, one, and
second, that, therefore, our observations of those properties
have to go on radically different tracks. We're just
not going to understand choice, for instance, by seeing whether
certain regions of the brain light up or not. I'm very,
very doubtful that that is going to happen.
CHAIRMAN KASS: Could I move us and maybe
try to refocus the question again, since Michael has given
us the suggestion that the patient actually might want to
know something about this?
And let's keep this case and its assumptions in mind
and also keep the related case of epilepsy in mind, just these
two things. Let's assume that for better or for worse
as part of the standard work-up for suspected antisocial personality
disorder brain scanning, fMRIs, becomes routine and you do
this study and you're now the physician or you're
What should Jones be told and why? And if you're Jones,
what do you want to know and why?
And keep in mind as a parallel I'm assuming that he
had had a seizure, and we'd had loss of comparable kinds
Is this different or is this the same?
DR. LAWLER: It's amazing you guys
separate brain and mind so clearly and metaphysically. I
thought I was the old fashioned guy on this.
Anyway, but abstracting from that, okay, let's say,
and it's probably so, I suffer from antisocial personality
disorder, which as Paul pointed out is a weasely and vague
title for something. All right. So I go in and I have an
fMRI and the doctor says, "Well, there's a correlation
between your brain and your inability to control your anger
I as an ordinary guy would say, "Yeah, sure. You mean
you're saying I'm hard-wired to have a quick trigger
In a certain way the doctor is not telling you anything
you did not already know. So when he tells you this, you
almost yawn, although you're glad to know this and go
home and tell your wife that, you know, "It's just
the way I am. You know, tough break," but you already
were telling her that. Now you have a picture that gives
you evidence of that, number one.
Okay. Number two, and the interesting question that Michael
was raising: well, what do you do with this information in
terms of leading a better life or whatever?
The old fashioned view, which still is practiced by all
psychologists, is various ways you could be taught self-control,
that you're still responsible for this. We all have strong
points and weak points in our brains, and you're responsible
for controlling those bad things you have a propensity toward,
and we all have some propensity toward some bad things.
So the old fashioned teaching is pretend like there's
a policeman next to you. Go to church. Like Aristotle, develop
good habits or something.
But what if? And this to me is the only interesting question
at this point. It could just be a purely physical fix. We
could then change your brain so that you no longer have this
propensity to have a quick trigger finger or lose your temper
And it seems to me it would be utterly disastrous if we
could do that, and I admit we can't do that, but if we
could do that, it would be utterly disastrous to start to
do that, although we should cure epilepsy if we could.
Dyslexia is kind of on the border because there are ways
you could cure it short of — you know, people can learn
to read without having their brains changed, and as Michael
pointed out, sometimes the brains change when they learn how
to read, right? So the cause and effect is not so clear here.
But in this particular case, it would seem to me that except
in maybe a very, very extreme case, such as a guy that's
going to go to jail and is going to go out and kill someone,
we shouldn't mess with this, right, because there are
certain advantages to having this kind of personality. We
might want this guy on the front line during battle. We might
actually want this guy to be maybe not a policeman, but maybe
a high school teacher.
DR. LAWLER: There are jobs for which
this sort of personality, this sort of temperament is an advantage,
right? And so I react badly to the idea that we —
CHAIRMAN KASS: Uncontrollable anger is
DR. LAWLER: No, I don't think it
is uncontrollable. If you read the case, this fellow, you
know, took up with Paul, got a good psychologist probably.
It could be controlled, right?
And then it was absolutely uncontrollable. It is an extreme
case, but if you read the antisocial personality disorder
characteristics, they are vague. I think I have two-thirds
of them. So it depends on the intensity with which you have
these things, right? So sometimes it may be direct physical
intervention might be the cause, but that would be the cause
of last resort.
I'm in favor of telling the truth except in the case
we talked about yesterday. So you should tell the guy there
is this physical connection, and when you tell him that, you're
not telling him anything he didn't already know truly.
But then you say we're going to do everything we can
to use ordinary, old fashioned, psychological means to bring
this under control, and only as a last resort would we intervene
And there will be a temptation in the future, in the Utopian
future described here, where these direct physical interventions
become easy to homogenize temperaments, and that I think is
the real danger here, right?
So my position would be — and also because of the
point Michael made — what we don't, right, is whether
if this guy responded well to Paul's old fashioned psychological
therapy that his brain would not, in fact, change, that the
impulse would diminish, right?
So I think this is not like epilepsy. Dementia, the difference
obviously with respect to dementia is temporal. There is
no psychological therapy for dementia. You can't make
that guy better through other techniques.
And I'm done because there are so many hands up.
DR. GAZZANIGA: Just as a question in
the intervention notion, do people have a problem with the
fact that the intervention might be surgical versus pharmacological?
So we take this problem and flip a blue pill and everybody
is fine. Is that socially acceptable, whereas the neurosurgeon
says, "I'll go in here and tickle his amygdala and
the person will be fine, too."
I'm just curious to know what the fear or what the concern
of an intervention is. Is it that somehow when you touch
the physical brain through surgery it's quite a different
thing kind of than when .-
DR. GÓMEZ-LOBO: Can I respond to
CHAIRMAN KASS: Could I make a procedural
comment? The subject of the actual intervention for behavioral
disorders is the topic of the second session and Dr. Cosgrove
is going to present that issue. We're at this point simply
talking about the uses of the information both to predict
and to intervene.
People wanted, I think, to respond either to Peter or Frank
and then Mary Anne.
PROF. FUKUYAMA: Well, and it seems to
me one way of thinking about this that might be useful to
distinguish this case from the epilepsy is just the economist
concept of moral hazard because, you know, moral hazard comes
up with insurance. If you insure against a certain kind of
behavior, you get more of it because the consequences are
mitigated, and it's a very common way of understanding,
you know, a lot of behavioral problems.
And it seems to me, you know, what really makes epilepsy
and dementia quite different from this case is that there's
no moral hazard in either of those. I mean, if you knew that
you had this biological diagnosis, I mean, there's nothing
in your behavior that would change that would make it more
likely that the behavior will come about.
Now, it seems to me that what happens in the other cases
where there is moral hazard is that, of course, you know,
scientifically you'd say there's some biological degree
of causation and then there's some, you know, degree of
individual responsibility. But the tendency in our society
is to take the information that there is some degree of biological
causation and then to run with that as far as possible.
And that's what leads to this general phenomenon we
discussed in this Council many times earlier of, you know,
this perpetually expanding domain of the therapeutic. And
we saw this before in ADHD where, you know, that's again
a situation where there are some patients where the behavior
is very heavily biologically caused and, you know, only a
small degree of individual responsibility, but there's
a large number of other cases where the two sorts of causation
are much more equal and where people could modify their behavior
if they wanted to or with help or whatever, but once they're
told that there is a biological foundation for it, they say,
"Great. You know, just give me the pill and let me stop
worrying about my own degree of responsibility," and
then it gets into all of the economic incentives with insurance
and everything else.
And so it seems to me that's really the problem with
this category of things for which there is moral hazard, is
that people like that actually, and they want to be absolved
of, you know, the individual part of the responsibility, and
so they never get accurate the relative weights of the individual
and the biological causation.
CHAIRMAN KASS: Mary Anne.
PROF. GLENDON: Well, this is a question
about whether — I'm really not sure, but I think
we may have already taken some steps along the lines of informing
patients and offering to them surgical and chemical treatments
for — I don't know the name of the disorder, but
what I'm thinking of is the violent, predatory sexual
Does it help to think about that case, where we're pretty
sure in some of these cases that there is a biological basis.
I don't know whether it's in the brain or somewhere
else, and here's where I'm a little unsure, but haven't
I read that some of these people are offered surgical and
chemical treatments and do, in fact, accept them as a condition
DR. CARSON: That has been done, and I
think that's going to be covered in the second section.
Actually that's part of the paper for the second section.
CHAIRMAN KASS: Rebecca and then Bill.
PROF. DRESSER: This point has some overlap
with what Frank said, but the very act of labeling the condition
as, all right, this seems to be related to the brain lesion
or whatever, I think we always worry about consequences when
labels are applied, and now I think in this case one of the
main, major areas of concern is social consequences of getting
But the other is personal consequences, and there's
a famous social psychology study, the Pygmalion effect where
children in first grade were divided into three reading groups,
the Bluebirds, Redbirds and some other birds, and they were
told, "Okay. You're in this group because your reading
ability is lower than average, average, or higher than average,"
and they were randomly selected, and at the end of the year,
they were tested, and they fell right into their groups.
So the lesson was that even though it was unconscious, the
teachers, the students, everybody was playing into this classification.
So in this case I think telling the patient that, well,
we think your behavior is related to this lesion would affect
that person's, as Frank said, understanding of the problem,
his roll in the problem, and probably affect how others treat
that person, and it could actually increase the chance that
there would be more behavior just because of getting the label.
Now, you have the same problem if the label comes from a
psychological testing classification, but because of this
tendency we have to put a lot of weight on physical explanations,
I think it would be a special danger here.
CHAIRMAN KASS: Bill Hurlbut.
DR. HURLBUT: That comment seems to me
to sum up one of the major issues here. I don't actually
agree with you, Peter. I think that when you go and somebody
tells you something about why something is happening, people
right now at least in the current phase of our culture are
inclined to take a scientific view, which has a certain element
of determinism in it and explain it away.
And I think here's really the crux of the question from
which a lot of practical issues flow, and that is what is
moral behavior. If it were epileptic seizures in today's
world, we wouldn't be so concerned about it. We'd
say, oh, a physical explanation. That's fine.
But when it comes to moral behavior, we feel with our folk
psychology at least, and probably correctly, that there is
something called freedom, and freedom is intrinsically not
determined. That's what makes it free, and that's
what may be the difference between our concepts of brain and
At the most fundamental level, we feel like the mind has
an element of something that you can't describe with a
scientific finding. The interesting here, for example, with
dyslexia, I have a paper in front of me done by one of my
colleagues, John Gabrielli at Stanford, where they did a series
of studies on children with dyslexia before and after some
remediation. This is mentioned in the paper, and it showed
a change in neural imaging after the remediation.
And so then you ask yourself, well, what's going on
there. Was the dyslexia just simply a physical cause and
what else would it correlate with besides dyslexia?
It turns out that there's a very high rate of dyslexia
among people on death row. So does dyslexia then also cause
Well, the interesting thing is maybe it correlates, but
the question is what's between that and the criminal behavior,
the dyslexia and the criminal behavior. Of course, there's
a whole process of personal existence, the sense of low self-esteem
that comes with failure in school.
And so it's sort of what you make of the finding. I
think we should face into this. It seems to me that in the
future we're going to see more and more quasi correlative
forms of quasi explanation. I don't think we should avoid
this issue. The mystery of human existence is that there
is something called freedom, and that's what makes us
moral creatures, but it's almost certain that that freedom
emerges from the fragile frame of our physical existence.
And it's much easier to correlate a pathology with a
cause than it is freedom. Freedom emerges from the whole
being. It's the right functioning of the whole being,
and therefore, it correlates with something that's a condition
but not a cause in a sense.
Finally, our highest order behaviors emerge not just from
our physical existence, but our process of identity formation,
our memories, our habits, and then, of course, our aspirations,
our beliefs and images.
And that's where I think many practical things flow
from that, but it seems to me that what we're really contending
with here is that mystery, that what we think of as our highest
order human capacities, our moral capacities are, in fact,
an emergent property of our whole frame of being, not somehow
of one identifiable locus of cause just like there's really
no brain that's a reification, a convenience of thinking.
There is no source of moral behavior except the whole being.
So is that right, Paul?
CHAIRMAN KASS: Look.
DR. McHUGH: Wow.
DR. LAWLER: Yes or no? Yes or no?
DR. McHUGH: First of all, I believe, I
absolutely believe that we're going to and have to appreciate
that freedom is what we're all working to have for patients,
and we're doing that with physical as well as mental conditions,
and freedom gets restricted in a number of different ways,
and ultimately freedom is not a faculty, but it is a psychological
experience itself of understanding the distinctions and choices
and taking responsibility for the outcome. Okay?
Now, we're capable of doing that because we have the
kind of brain we have, but it permits us to have the kind
of mind we have, which relates to that brain in a very special
way, and it's unique to humankind as far as we can tell.
And that was all swept under the rug by Steve Pinker and
all of that, and we should obviously salute that view.
I just don't think we can start, Bill, from that position
to understand the questions that have been raised around this
table about moral hazard, about the dementia question.
I remember so well what Rebecca is talking about because my
children were in school at that time, and they were getting
various kinds of slips. So I know all of that.
I don't think though we can answer the questions that
are raised here from that level. We've got to work at
another level to understand what the primitive field of psychiatry
is about and how it will relate to these problems.
CHAIRMAN KASS: Could I? I think we really
have to come down to the more concrete question rather than
deal with this thing at the most global level. You've
got a dangerous guy here. This is a fellow with an explosive
temper and lack of self-control. His family is bothered by
it. Even if he doesn't feel remorse, he's at least
willing to go and try to seek some kind of help.
As part of the work-up, they find out that there might,
in fact, be something which it's not epilepsy, but there
might be some kind of organic contribution to his inability
to exercise self-control.
And never mind what I think as a philosopher. Here's a patient,
and there is this kind of correlation, and I would be surprised
if this correlation is meaningless. Quite frankly, I would be surprised
if the people who have explosive temperaments and who have no capacities
for self-control have perfectly normal brains. It would surprise
That there would be a lot of abnormality that winds up eventually
in prison I don't think should surprise us, whatever our
philosophical view is, dualists or what.
And here is a question. I mean, here we have this kind
of information. What use should we make of this information?
That's a kind of retail question. It's not the question
for the Council of Metaphysics.
What do we tell him? What should he do on the basis of
this kind of knowledge or is it knowledge?
DR. GAZZANIGA: What's the problem?
If Mr. Jones has X wrong with his brain and we have a pill
that fixes it, fix it. Next question?
CHAIRMAN KASS: There you are.
DR. GAZZANIGA: I mean who's lessened
DR. CARSON: Well, it's not that.
CHAIRMAN KASS: There are all
kinds of people who I think are trying to undermine the force and
potential usefulness of the findings. He (Frank Fukuyama) talks
about the moral hazard of making such a diagnosis. She (Rebecca
Dresser) talks about the trouble of labeling. He's (Paul McHugh)
worried about contributing to some kind of purely reductionist view
of the human spirit. Bill (Hurlbut) is worried about freedom.
I was waiting for Mike to say, "Look. Here is biological
information relevant to the person's well-being, never
mind society's well-being. Here is information that he
should be told about, and insofar as there is effective treatment
available, he should be encouraged to get it fixed.
DR. GAZZANIGA: Sure, why not? I mean,
but let's go back to —
CHAIRMAN KASS: Like epilepsy or other
sorts of things.
DR. GAZZANIGA: Well, there are drugs
that are active and help schizophrenics, and they fix the
dopaminergic system. You tune it up and pretty soon people
are in fairly good shape.
That solution doesn't ever touch the question of why
did that guy think he was the king of Siam before the medication.
No one has any idea how that works. The same with this.
So you can just fix it. Fix it and worry about all this
other stuff in some other context.
DR. CARSON: Well, one thing we have to
recognize even about the epilepsy case. When people have
lesions, we see them. We don't jump to surgery automatically.
If they can be easily controlled some other way, then they
generally are controlled some other way. Surgery is usually
not number one on the list. In some cases it is, but not in
The other thing to keep in mind is let's say this guy
— and we have found some abnormality in his amygdala.
It doesn't necessarily mean that because there's an
abnormality there we want to go do something physical to it,
but the reason that people have envisioned a physical response
is because there have been numerous cases of people who have
had rage type behavior and have had a tumor in that area.
We have gone and taken the tumor out, and the behavior has
It was the same kind of thing that led to the interventions
for sexual predators. Because people had tumors there, they
went in, took it out, the behavior resolved.
So you know, this is not something that came about just
because somebody saw an abnormality. There really have been
correlations for these things.
DR. McHUGH: Can I just come into this
very important discussion that Ben and Mike have brought out?
The problem for me is not whether you, if you have an effective
pill, whether you shouldn't use it. It is, one, what
you're using it for and what are the consequences as well
of having used it.
If you're simply using it in antisocial personality
to reduce the responsiveness of the patient, it is the same
thing as saying to the antisocial personality, "Never
take alcohol because that raises your threshold for anger."
So I have no objection to that.
What I have an objection to is when you demonstrate that
this does lower his short trigger, that you then say, "Well,
you see, because we're able to do it with this, therefore,
he doesn't have any responsibility the other times when
we didn't have the pills and he shot his wife."
The fact that you can alter the temperament up and down
doesn't change a bit the moral question, which was part
of the things that made this really an interesting question
at this point.
CHAIRMAN KASS: Everybody. Let's
start Michael, Bill, Peter.
PROF. SANDEL: Well, I have no objection
if it really will make him better, all things considered,
though what counts as better is something we would have to
investigate from social, moral, as well as physiological point
So I don't have any problem with Mike's answer if
it really will make this person, all things considered, better,
but we have convened in this session as the President's
Council on Biometaphysics anyhow. I don't think we can
PROF. SANDEL: So I just want to respond
to the worry. There is a common worry, and it has been voiced
around the table that freedom is at stake here. Freedom is
threatened by scientific explanation or a fuller picture of
the correlations in the brain.
I think that's a mistaken idea of freedom because it
conceives freedom as consisting in and depending on gaps in
scientific explanation, and then the reason it depends on
the idea of gaps is because it assumes that freedom is the
capacity of the will to initiate uncaused action, action that's
uncaused in the sense that it doesn't have some physiological
And I think that conception of freedom is a mistake, but
we probably don't have time to explore that here, except
by way of going back to some concrete cases.
It was said, perhaps, Leon, well, it wouldn't be surprising
if criminals had some abnormalities in their brains, but then
wouldn't we also say that the same would be true for saints?
If we were to give scans to Mother Theresa and we found that
there were features of her brain that we could identify that
were different from less saintly people, that shouldn't
surprise us any more than it should surprise us that criminals
have certain features that are not true of the general population.
Now, that isn't a threatening finding I would say.
It's not threatening to the idea that certain people are
saintly and others are criminal or sinful. I don't think
that those two descriptions or that scientific discovery in
any way undermines the saintly or the criminal as a mode of
moral discourse and judgment and understanding.
There was an experiment someone did once. I don't remember
who did it, who wanted to find out how much the soul weighed.
Do you remember reading about this? And so he did experiments
by sitting near terminally ill patients and putting them on
a scale before and after, and at the moment of death figuring
our how much the weight went down when the soul departed.
And it turned out that, you know, the soul weighs, you know,
2.5 ounces or something like that. Now, that experiment,
I don't think that experiment proves or disproves the
existence of the soul. It's surprising it weighs so little
CHAIRMAN KASS: I'm sorry. I remember
Do you want to quick to that because Bill was next?
PROF. MEILAENDER: Yeah, interestingly
the second question on page 5 used the language "abnormal."
What more would we need to know before an abnormal neural
Is the thrust of your point, Michael, that we shouldn't
actually we talking about an abnormal neural image but just
a different neural image?
And if that's true, would — and this is really
not just for you, but I'm just thinking with you —
if that's true, would we want to say the same thing in
the case of the demented patient, that there wasn't anything
about it that we'd call an abnormal image, but just a
I mean, I'm trying to figure out whether these cases
really are different sources of cases or not.
PROF. SANDEL: Well, I'm trying to
understand what's your —
PROF. MEILAENDER: Well, we've got
saints and we've got incarcerated people, and we've
got the rest of us who float around somewhere in between.
PROF. SANDEL: And if it turned out that
we could find some pattern between the brain scans are the
same of the criminals and the people in between.
PROF. MEILAENDER: I wouldn't call
any of them abnormal. I would just say here are these different
ones, and they're correlated with people we call by different
PROF. SANDEL: Well, it might or might
not be useful information. If that's the question, we
might consider the brain scan of Mother Theresa to be extraordinary
and the one of the criminal to be —
PROF. MEILAENDER: Well, that would just
mean it's just statistically abnormal, which isn't
a whole lot different from different.
PROF. SANDEL: Well, these descriptions,
I think, only matter from the standpoint of possible interventions,
but whether the intervention is (a) desirable and (b) effective
is a further question.
PROF. MEILAENDER: But if we said that
the image of the brain of the demented person is abnormal,
we would mean characteristic of a person who cannot really
function fully as an adult human being does when reasonably
DR. McHUGH: Can I translate that into
physical medicine for you to make it clear what I think is
PROF. SANDEL: Yes, yes. We try to treat
DR. McHUGH: I think that this issue that
you're raising Gil and that you're pressing Michael
on is, in fact, something that doctors are very accustomed
to. You take a baseball player who is at the top of his game,
and he's 33 years old or 34 years old and his batting
average is beginning to fall off, and he tries and practices
and works away to see if he can get his skills back to where
it was before with new weights and new exercises. And it
fails, and he goes to the doctor and the doctor says, "You
have amyotrophic lateral sclerosis. It is a disease of your
And of course, we're talking about Lou Gehrig. If you
look at the general batting averages of baseball players,
they fall off in a very particular way. It's associated
with a statistical change in the muscular structure of men
as they age, but in Lou Gehrig's case, you can see the
batting average falls off the cliff and you have a real pathology
in the tissues that have got nothing to do with the statistical
change. You have a new process in action.
These things relate to what you're going to tell Gehrig
what he can do and what his future is, and it's going
to generate, and it's going to generate all of our scientists
to want to find a cause for that amyotrophic lateral sclerosis
so that we can prevent it in the future.
That's what happens, and that's the difference between
somebody who has a dementia that is falling off and a new
process is in action versus somebody who, like me, doesn't
have quite the same capacity that he had when he was 30 to
remember the names of all my friends and some of my acquaintances.
This is a natural process, and the other thing is a disease.
And dementia is that, and that's how we come at this issue.
CHAIRMAN KASS: And what are these behavioral
disorders of this sort?
DR. McHUGH: In relation to this?
CHAIRMAN KASS: Yeah.
DR. McHUGH: These behavioral disorders,
if you want to call them — I call them temperament disorders
or personality issues — they are the different forms
of our constitution in which we have a Bell shaped relationship
in the world, and we're at some place along these dimensions,
and they express themselves not only in our behavior, but
very much more clearly in relationship to our emotional responsiveness
to the situation.
We're extroverts versus introverts. We're more
unstable, unstable. Those things are biologically built in,
and they are responsive to biological measures because nothing
happens in our mind that doesn't have some correlation
with something happening in our brain. It doesn't happen
any other way, and we have to think of them though in quite
different terms than we do in relationship to the diseases
that reflect the organ that generates it. Hence, the difference
between dementia and mental retardation, ordinary physiological
mental retardation, and in relationship to these behavioral
disorders and what we would do about them and imply from them.
CHAIRMAN KASS: Bill.
DR. HURLBUT: That strikes me as the right
way to frame it. Obviously, whatever else we are, we are
chemical, and whatever else we are, we're going to find
patterns of brain circuitry for every behavior that we manifest,
but that doesn't make the pattern of the saint somehow
the same as the pattern of the criminal. Obviously they would
be different patterns, but one could manifest its phenotype
or its overt behaviors as a manifestation of a weakness, whereas
the other could manifest the fuller integrated functioning.
That would give them quite a different moral meaning and quite
a different practical meaning with regard to what we do with
our emerging science.
The criminal might be doing what he or she does in a sense
by having a missing link in the chain of freedom, whereas
the saint may be doing something from an extraordinary level
of freedom. And that seems to me very different reality.
And so what I'd like to ask Mike, based on what you
said a few minutes ago, are we going to end up with two categories
of crime eventually? One will be pathological crime and the
other will be freely generated crime. One of them goes to
the hospital and the other goes to jail?
DR. GAZZANIGA: I don't think so,
but that's another story, and I'll send you an article
I wrote on it though.
DR. GAZZANIGA: But let me raise maybe
an orienting question or orienting point for all of us to
think about. If you are an evolutionary biologist and you're
trying to understand something, what's the first thing
you do? You ask, well, what is the thing for that I'm
trying to understand. So if it's a kidney or liver or
heart, you go find out what it does, and then you figure out
how evolution fits into that picture.
So the question with respect to the nervous system is what
is the brain for. You've got to ask that question.
Does anybody here? Do you all know the answer?
I know the answer. It's there to make decisions. It's
a decision making device. And if we're going to understand
how the brain plays a role in all of these things we're
talking about, we're going to have to understand how the
brain makes decisions.
It's making a zillion decisions as we sit here on 100
different levels, from eye movements to breathing, to talking,
to trying to formulate a sentence, all of these things. It's
a decision making device.
What does neuroscience know about how the brain makes decisions?
Basically nothing. We're all kind of working on it.
People are doing elegant experiments, but how it all comes
together into making the final decision, a final decision
that is being made, is just the great unknown in neuroscience.
In these kinds of things we're just discussing, we're
dealing where we have maybe genetic dispositions to particular
temperament. There are biasing decisions. We're affected
by our somatic system in these decisions. We're affected
by our past experience in these decisions. We're affected
by a zillion things, but once you just sort of get out of
the mystique and just ask yourself the question, what is the
brain for, it is the decision making device, and that's
how we're trying to understand its role in all of these
issues that we're dealing with. That's what it is.
PROF. SANDEL: But then the question is
one of the best neuroscientists might turn out to be Dostoyevsky.
DR. KRAUTHAMMER: I think I have stumbled
in on a seminar on metaphysics here. But, Mike, there's
a difference between the organ of the brain and the organ
of the heart. You don't go to jail if you have an arrhythmia,
but you do go to jail if you make the wrong decision. So
that's why you have to introduce the metaphysics, and
you can't be ultimately a reductionist.
I think the real question is, you know, is antisocial behavior
just as Gil was implying in this question, you know, one end
of a normal distribution of adaptation to societal requirements
or is it a medical abnormality.
The question, I think, here is medicalizing sin, if you
like, or criminality or bad behavior or bad decisions. I
think it's a critical question, and if you give the guy
a pill and you say you've solved the issue, you haven't.
You have to decide whether or not he's responsible for
what he did, and that requires answering the question. Is
this a disease, in which case we would assume he isn't?
If a person is schizophrenic and he kills someone assuming
he is the king of Siam and the other person is a pumpkin,
well, you'd say, "Well, he doesn't go to jail."
But if it's not a medical abnormality he does go to
jail. So I think it may sound abstract, and it isn't
metaphysical, but in the end it's extremely practical
as a question.
DR. GAZZANIGA: I think you have to recognize
that this decision making view of the person finds that person
able to learn rules and to follow them. Schizophrenics stop
at red lights, right? They know how to take a rule and follow
it, and to call upon most sorts of disease cases as being
exculpatory just doesn't work.
DR. KRAUTHAMMER: What about Hinkley?
DR. GAZZANIGA: I know it has been done.
I don't particularly agree with —
DR. KRAUTHAMMER: Well, and you're
saying it shouldn't have happened.
DR. GAZZANIGA: Yeah, I don't think
it should happen.
DR. KRAUTHAMMER: We shouldn't have
an insanity defense.
DR. GAZZANIGA: I don't agree with
DR. KRAUTHAMMER: It's a fairly practical
DR. GAZZANIGA: It's a very practical
position, but it's also such a teeny part of all court
proceedings. Less than a quarter of one percent is it ever
used by —
DR. KRAUTHAMMER: Oh, you don't think
it's an important question?
DR. GAZZANIGA: Yeah, yeah.
DR. KRAUTHAMMER: A man assassinates the
President of the United States assuming that he's —
DR. GAZZANIGA: I'm just not particularly
in favor of the insanity defense.
DR. KRAUTHAMMER: I assumed that.
CHAIRMAN KASS: Frank, take the last.
We're going to take a break. Frank, take the last comment.
PROF. FUKUYAMA: I can kind of formulate
my answer to this question that Mike posed a long time about
what's wrong with just fixing this, and I think it was
involved in this interchange between Michael and Gil.
But I think another thing wrong, apart from this responsibility
issue, is in the question of how we define abnormal. Now,
the case takes, you know, this propensity for uncontrolled
violence, which almost anybody would agree is not socially
desirable, and I would say, Peter, it's not good in high
school teachers. It's not good in soldiers. I mean,
it's very hard to imagine a case where it is good.
But there is a kind of precedent and slippery slope issue
involved here because I think what people would worry about
is the sort of One Flew Over the Cuckoo's Nest
kind of behavior, you know. DSM is a book that's got
oppositional disorder, you know, in it as an officially recognized
disorder, and if you remember the Ken Kesey novel, you know,
McMurphy goes into this asylum and it turns out that all of
the inmates are in there voluntarily because they're just
afraid of being out in the world, and so he tries to take
them out in the world and, you know, this is regarded by Big
Nurse as, you know, clearly antisocial behavior, and then
he is given the lobotomy and, you know, everybody then ends
But it does seem to me that there's a large other category
of behaviors that are not, you know, sexual predation and
not uncontrolled propensities for violence where, you know,
the good aspects of behavior are all tied up with things that
are, you know, much more questionable.
And I guess, you know, you're kind of opening up the
possibility of biologizing that, too, and you know, raising
these questions. Then do we know what, you know, so clearly
And I think the precedent from the discipline of psychiatry
is, you know, a little bit troubling because there are a lot
of things that are considered abnormal which, you know, may
I mean, homosexuality is a good case of that. It's
all very politicized and so forth.
CHAIRMAN KASS: Yes. Look. We did only
partial justice to what's here. I think to —
PROF. SANDEL: I'm not sure if it
was partial or excessive justice.
CHAIRMAN KASS: In a way our conversation
will continue in the next session when we're dealing with
specific interventions for behavioral and psychiatric diagnoses,
but just as an observation, it seems to me — and I'm
guilty of this myself — to talk about biologizing something,
to give it that label and, therefore, to let that label do
the sort of work of defeating its desirability, I think, is
going to be insufficient here.
You remember the case of the guy who went up in the tower
at the University of Texas with a machine gun and shot up
the place, and one's attitude about what that was changed
dramatically when, after they shot and killed him, it was
disclosed that he had a tumor in the temporal lobe. One might
want him eliminated; one might want him incarcerated, but
one would not have put that guy on trial and held him morally
responsible for what he did. That's a clear case.
These kinds of cases become less clear, and even if Paul
is right that with the policeman standing next to the guy
he wouldn't have beaten his wife, nevertheless, we move
from an area where something is absolutely clear to something
where there might, in fact, be major biological contributions
to the lack of self-command.
And to simply name it as biologic in this thing as if that
was somehow going to be sufficient in a climate where this
kind of evidence is going to become increasingly important,
I think, is to miss the force of what's coming even before
science can explain fully how the brain is a decision making
These cases are beginning to come forward now, and the question
of how this bears on moral and legal responsibility can't
be answered, I think, because we worry about the slippery
slope. We have to, I think, face it directly.
Let's take a break and we'll convene at 20 after.
DR. GAZZANIGA: Just one point though.
CHAIRMAN KASS: Please.
DR. GAZZANIGA: There are plenty of patients
with those same temporal lobe tumors who don't go up and
shoot up a campus.
CHAIRMAN KASS: That's true.
DR. KRAUTHAMMER: And there are plenty
of schizophrenics who don't do that either.
(Whereupon, the foregoing matter
went off the record at 10:08 a.m. and went back on the record
at 10:20 a.m.)