Transcript, Meeting 19, Session 2

Date

November 5, 2014

Location

Salt Lake City, Utah

Presenters

Member Discussion

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Transcript

SESSION 2: MEMBER DISCUSSION

DR. GUTMANN: We will spend the rest of  the day deliberating about the potential  recommendations to the President and the discussion  behind those recommendations. The President's charge to us is very  broad. He asked us to examine ethical consideration of  both neuroscience research and the application of  neuroscience research findings. We provided our initial response earlier  this year in Volume I of the Gray Matters report  stressing the importance of ethics integration early  and throughout neuroscience reports. And I'm pleased to report, actually, that  NIH and other agencies are taking this seriously and  convening groups, including bioethics experts in their  deliberations. And that, really, we shouldn't take for  granted because, as Raju and others have pointed out,  this is the way the development of genomics actually  was -- avoided having the sort of heavy hand of  regulation, rather than actually integrating early on. And so that was basically the headline of  our report: Integrate ethics in neuroscience and  integrate it early. And the rest were details. So we have discussed ethics and  neuroscience for some time now, several years,  actually. We have had meetings on and off about this.  We laid the groundwork for this project at meetings in  2011 and 2012. A long time ago. And we received the  President's charge last July. We are going to bring  together the topics that we have discussed over the  past few years to formulate some of our thoughts and  our recommendations. And there are three areas, three particular areas that have stood out in our discussions  as ripe for elaboration, for different reasons. Some  of those areas are ripe for basically showing what the  understandings and misunderstandings are and they may  not lead to any strong recommendations other than to  educate people on what an accurate knowledge and  understanding of this is. And other of these topics  may be ripe for some recommendations that are more  policy specific. We will see. Here are the three areas: First -- and  these are only in order that we are going to deliberate  them, they are not in any particular order except  perhaps going from more general to more specific. Cognitive enhancement, we already began  discussing. We are going to do that in this session.  Second, Consent Capacity. We'll do that second. And  third, Law and Neuroscience. We have three discussion sessions on our  agenda today and I hope that we can devote each session  to one of these topic areas. And I would like us to  focus on two critical questions that we will address in  our report. One, what should we say about this issue  in our report. And two, what specific recommendation  or recommendations should we make. And let's start with cognitive enhancement,  which can include the use of neuroscience drugs and  technologies. And it can be on-label, off-label,  direct-to-consumer use. Many considerations emerge.  We have already introduced some of those considerations  in our earlier session. And I thank Lisa Lehmann, and  I thank the presenters, Serena and Margaret, for  getting us started here. I want to focus our discussion on what to  say about this issue in our report and what specific  recommendations we should make. And I have the great pleasure of  introducing Steve -- Dr. Steve Hauser and Dr. Anita  Allen who will take us away on this. I'll moderate it. But Steve, I understand  you are going to start and then Anita is going to step  up to the plate and then we'll just open it up for  Commission discussion. And again, anybody who has a question or  comment, please write it down and we will bring it up  here. So, Steve, please begin.

DR. HAUSER: Thank you, Amy. We thought we would finish strong, so  Anita will finish for us. I will be brief and speak mostly about two  things. First, a very brief overview based upon what  we have heard in numerous earlier meetings and also  this morning about where we might focus thinking about  the landscape of cognitive enhancement and what we are  speaking about. And second, mention some thoughts and  ideas for principles and directions that we might  explore further. And then Anita will speak more  specifically about possible recommendations that the  Committee could think about. So just to begin, and Amy spoke about this  in the introduction, what are we talking about in 2014?  What is real? And really, there are three things that  are real. The first are drugs. These are in several  categories. They are the stimulants: Methylphenidate,  Ritalin, dextroamphetamine, other related drugs,  Adderall. These we know work through very specific or  relatively specific stimulation pathways that might  improve focus, as well. The second is a broader class of drugs  that work on different and multiple transmitter systems  in the nervous system: Modafinil, Provigil is the  trade name, or Nuvigil. Drugs that initially were  developed for sleep but now may have broader off-label  use. The third category are cholinesterase  inhibitors which, by their name, work on cortical  cholinergic neural pathways. Drugs like Aricept,  developed for memory impairment but may also have  broader use. And we spoke this morning about other  types of drugs, most of which are stimulant related,  that may include the caffeine that most of the  Commission members enjoyed this morning. So drugs are the first. And I would say  also about the drugs, that for all of these off-label  uses, most of the evidence thus far shows incremental  if inconsistent effects in healthy populations. The second big area we could call brain  stimulation or brain modulation for cognitive  enhancements. We've heard about transcranial magnetic  stimulation which depolarizes nerves, it activates  nerves. It is FDA approved for depression but also  incrementally useful. Other developing methods, direct  current stimulation that changes the baseline  electrical level, the resting potential of nerve cells,  but doesn't actually turn them on. And then the third, also discussed this  morning and earlier, are neuroscience-based enhanced  learning tools. In addition to those that are  marketed, there are a number in the academic world,  some of them video games focused on activating or  altering frontal pathways that interact with cognitive  learning and behavioral systems. So those are the three: Pharmaceuticals,  electrical adjuncts, and enhanced learning through  neuroscience. So we heard many times, and Amy said very  clearly this morning, what I think all on the  Commission agree with: There is nothing inherently  wrong with the concept of cognitive enhancement. But  one question that we asked earlier is are there limits,  and if so what are the limits. Is there an equivalent  to human cloning, a decision that no human cloning  should take place in the cognitive enhancement arena? Without a clear answer, how will that  decision be made? How will those decisions be made?  What buy-in will be important? What if down the road,  certainly not today, we can begin to think about  constructing neural -- human neural systems,  transferring attributes into experimental animals, or  even mimicking a human nervous system with software? We have spoken about the risk/benefit  profile which will guide and should guide the use of  therapies deemed reasonable. There's probably no such  thing as an intervention that's completely safe. And  it's an issue of benefits that need to outweigh the  drawbacks, and honest discussion of what is known and  what is not known. We have spoken about other issues:  Authenticity, potential for coercion, fair access,  distributive justice. Does this cheapen  accomplishments if it's easier to do things? But I think that as we are preparing our  report we should focus on the real issues as well as  those that are maybe not so real, and recognize that  there are some issues that can be solved by reasonable  people and others that will be far more difficult. And to paraphrase what Thomas Murray said  to us, formerly from the Hastings Center, a key will be  not to handle the marginally useful things that we have  in November 2014, but how do we handle the surprises.  How do we handle the larger achievements? And how do  we proactively prepare for these future developments  which may be unexpected? So I would close by just raising two  concepts that we might want to dive in a little deeper  as a Commission. We might broaden the concept of  cognitive enhancement to think about the range of ways  that the human nervous system can be enhanced. And  this involves, importantly, motor, behavior, as well as  cognitive enhancements. There's a lot of science that  the capacity to cooperate with others, to delay  gratification even in childhood, to regulate our  emotion may be as or more important than specific  elements of an IQ or cognitive response in determining  success. And success and happiness are not always  linked. So I think that we should broaden this  concept. Motor enhancements are an area that is being  used broadly off-label and sometimes to the detriment  of young people and not-so-young people. There will  also be other attributes that neuroscience can arguably  enhance. Some would argue maybe this is not an  enhancement. What about short sleepers? We used to  think that if you didn't sleep much, this was  dangerous. But recent studies of short sleepers show  that they live very long lives, they are often  successful, and they tend to be inherent optimists. So  understanding the clock genes that regulate our  circadian pathways, there will likely be novel sleep-  promoting or less sleep-requiring opportunities. And I  think whatever we do should consider a broader range of  ideas, as well as the likelihood that better ways to  inhibit myostatin and build stronger muscles -- we all  know about the steroid and related compound issues in  sports. And then -- so the first would be to  broaden the concept of cognitive enhancement to a  broader neural -- enhancement of multiple neural  attributes. And the second was addressed, in part, in  our first report but is so important that we cannot  lose track of the importance of promoting an informed  public. And Stephen Ward from Oregon put it more  bluntly than many of us would. A key challenge, he  said, is how to deal with the baloney. And I think very similar to our synthetic  biology report, how can we speak in a useful way about  goals for promoting education, communication, fact-  check mechanisms, how to put real teeth into these  concepts.

DR. GUTMANN: Thank you very much. And  bravo. I think you've helped us outline a way of  proceeding, so it's really terrific. Raju, can we hold and do Anita and then  open it up? And you will be first.

DR. KUCHERLAPATI: I don't know what Anita is going to talk about but I have some specific  suggestions to what Steve talked about.

DR. GUTMANN: Great. Terrific. So you  will be first and we will just have Anita go and then I  will call on you.

DR. ALLEN: Thank you. And I think that  much of what I'm saying is going to be an echo to what  we just heard. I think that one of the directions which  would be useful to go would be more research; research  about what we know about the prevalence of enhancements  and their safety and efficacy. And in the prevalence area I was struck  this morning by how little we know about the exact  prevalence of usage among high school students or  college students, the general public, the worried well,  the elderly. To what extent aren't the newer  interventions being used and by what populations and  for what kinds of reasons. So I think that's an  important thing that merits funded research. And at the same time, I think as we are  looking at new pills and other sorts of pharmaceuticals  we should also be looking at the prevalence of  deliberate changes in behavior and environment and  education that are aimed at cognitive enhancement.   As Steve was suggesting, we could very  much stand to explore and recommend that others explore  why we care about cognitive enhancement. Why is it  important? Is it because we care about addressing  congenital problems, defects? Do we care about  accident victims? Do we care about mental disorders?  Do we care about aging? Knowing why we care might also  be helpful to point us in directions about what kinds  of other research and ethical measures we need to be  undertaking. I think that there is a sense that we care  because we think it's a good thing to be,  quote/unquote, normal. And what it means to be normal  of course changes. Normal is not exactly an uncritical  norm, as it were. But I think people value self-care,  they value relationships, they value economic and  political independence. And if cognitive enhancements  under that name or some other can actually bring people  closer to normal lives, that would be a very good  thing. So then research, research on prevalence,  safety, and efficacy. An excellent point that was made  this morning about safety. If you just think about the  safety of taking one methylphenidate tablet every time  you have a math exam, it looks like it might not be all that unsafe. But if you think about it in the context  of young people who might also be consuming other kinds  of pharmaceuticals plus alcohol, caffeine, et cetera,  then the safety of the intervention becomes much more  problematic. So we need to think about the safety of  these interventions in a much broader way than just  looking at the pill itself or the drug itself. You know, we need to know more about the  efficacy. If, in fact, people don't get as much as  they think out of the drugs and the drugs have risks  for heart conditions or blood pressure, we need to then  know that better and educate the public about the  limited efficacy of the drugs that they might be  inclined to take. So, more research there. Another thing I think we should be  thinking about is the importance of just old-fashioned  self-help, self-care measures. We focus a lot on the  complex new pharmaceutical interventions and brain  interventions but we don't focus as much as we should  on just what things within our control that we can do  to make our lives better and enhance our cognition. So we should definitely put a priority,  recommending that a priority be placed on educating the  public and the medical profession as to the importance  of exercise and sleep and lead abatement and better education in schools because, of course, are stimulating  young people's brains may be the best enhancement of  all. But the behaviors that we can change and  address to make ourselves healthier need to be  addressed. I mean, if alcohol -- alcohol is an  anti-enhancement for most people. Let's cut down on  drinking alcohol. So the things that we can do within  our control, the things we can teach people to do that  are very inexpensive need to be emphasized more. And I  would certainly want us to be recommending that we do  something to improve the priority given to ordinary  interventions in this area for those kinds of reasons.  We do care and we can do something about it. Of course, once you have in place access  to products that enhance cognition and you have in  place programs and educational schemes that are  designed to make people more aware of the value of  diet, exercise, sleep, et cetera, questions arise  about, well, do all consumers -- does everyone have the  same access to this kind of knowledge and these kinds  of opportunities. Good food is not something which everyone  has access to. The ability to sleep well is something  which is maybe more available to some people than others. But if there are concerns about access,  especially to expensive pharmaceuticals, we need to  have, from a justice point of view, some kind of  structures in place to ensure that we don't have a  population of the haves and have-nots. Those who can  afford the great education, the access to sleep, the  wonderful diets, and then those who, by virtue of  poverty or isolation, have no access to similar kinds  of self-help and ordinary remedies to improve and  maintain brain function. Another set of issues that we need to  worry about, or mentioned by Steve, they have to do  with coercion. I think a lot about this. If you have  in place -- again, whether they are new, novel  interventions or just reemphasizing of common sense  like sleeping more, there are concerns about coercion  and whether people who perhaps would not want to adopt  an intervention should be in some sense coerced to do  so. Whether children should be, by their parents,  coerced to take medications or engage in other kinds of  behaviors or strategies in order to make them better  functioning, from the enhancement point of view. To what extent do we force people. Do we  force people to force their children, and so forth. Do  we force people who are incarcerated. To what extent do we use what we think are proven, reliable, safe, and  effective enhancements? Do we use those in a way which  involves coercing people who might not want them to  nevertheless get on board with the program. With that in mind, it's important to have  guidelines for practitioners and public policy folks,  because if we are going to go down this path, there  should be uniform standards used by nurses and doctors  and psychiatrists and psychologists who don't have a  world in which some people are, because of anxiety,  being given drugs of one sort and others are given no  drugs or drugs of some other sort. We need to have it  clear what's a reasonable and effective and safe  protocol for treating and addressing different kinds of  problems. And I think it would be great to give people  greater guidance. Because even the psychiatry  profession itself is sometimes not as well-informed  about the various options and what the social and  medical risks are of those various options. So guidelines for everybody would be  helpful. It would also give -- parents need guidelines  on when to pursue the medication route, for example, as  opposed to other kinds of interventions. Lastly, I want to say something about this  very important topic that Dan raised about ethical assessment. I think that we need to be recommending  that ethicists spend a great deal of time as we move  forward assessing whether or not we want to go far  ahead in the area of enhancements. Do we want to get  to normal or do we want to get to super human? I think we've all been inundated these  days by video games and science fiction images of  humanity where human beings are Cyborgs who have  extraordinary extra-human capacities. Well, if science makes that possible,  should we go that way? Should we go that way with  humans, with animals? What's wrong with that? Is  there anything wrong with wanting to be better than we  are? How do we balance the virtues of humility with  the very familiar hubris that goes along with being a  human being, as well? And what role will drug  companies and the government play in either pushing  forward in this very, very fraught with ethical concern  domain of super enhancements? How much will they  restrain the capacity to go in those directions. And  what do we lose by way of human authenticity and  character if we allow ourselves to become not just  human but super human?

DR. GUTMANN: Great. Thank you. Raju.  

DR. KUCHERLAPATI: Terrific. Both of you.  That's a terrific start. I'm going to make a couple of comments  that we might want to think about incorporating in our  report. Some of them might be obvious, but let me  state them. First of all, I wanted to point out that  the way that we are talking about neuroscience now, in  the context of that report, encompasses actually lots  of areas of science and medicine that were considered  to be distinct. I think that, you know, for example,  neurology and psychiatry were completely different  sorts of entities for a long period of time in how  people train, how they take care of people, and so on  and so forth. But now it is emerging that those are  not two distinctive fields, but they're the same. Similarly, neuroscience is a separate  entity, or studying worms or some other sorts of  things. But now, you know, we are trying to bring  together all of these different types of things. And  of course, other sorts of medical fields, like  geriatrics and pediatrics are also becoming an integral  part of all the things that we have talked about. So I think we should talk about that a  little bit in the beginning of what it is when we talk about neuroscience, neuro ethics. What are we talking  about? And trying to, Steve, like you suggested, to  make it broad. The second comment I want to make is that  much of the stuff that, you know, both of you talked  about, we have to put that into context. So what I  mean by that is that, first of all, we have to define  that there are, you know, human pathological conditions  under which it is necessary to intervene and to try to  enhance cognition, right? So people like me who are getting old, you  know, might -- because of age might require cognitive  enhancement. Or people who have a disease like  Alzheimer's would need to have cognitive enhancement.  Or in the case of children, we can debate whether ADD  and ADHD, you know, whether they need this, but  certainly the people who take care of them think that  such type of cognitive enhancement is important and it  is necessary. And we have to separate those types of  cognitive enhancement as opposed to so-called normal  people and how we deal with them. Right. And the other comment that's very -- so  certainly in the case of disease areas, certainly in  other fields -- for example, if a person is diagnosed  with stage 4 cancer, for example, and they think that they have only two months to live, there may be  extraordinary types of things, drugs that would be  given to them in an experimental fashion that would be  considered to be okay, right? Whereas such a drug may  not be appropriate for somebody else in another  condition, right? So there are certain sets of circumstances  when, you know, unusual types of treatments may be  okay. We have to define that that's indeed the case. With regard to normal, so-called normals,  if we look at the population, with regard to anything  that we talk about, any aspect of the human aspect of  it, you know, height or intelligence or cognitive  ability, it's a bell curve, you know? There are people  all over the place, right? And so what are we talking  about here? Which of those populations are we talking  about, right, when we talk about these types of things? Again, maybe at one end of that spectrum  it is okay to be able to do certain types of things  that may not be okay at the other end. So unless we  truly recognize that there is a significant amount of  variation, and how you deal with them is important. So -- and I just wanted to talk about some  of the things, like the drugs, for example -- you know,  you give Ritalin to children who are diagnosed with ADHD, or something, and some children respond and other  children don't respond. It may have nothing to do with  the drug. It may be our understanding of it, what the  disease is, what the underlying basis for the disease  is, and what the target for this drug is, right? And that type of thing is happening in  other areas of neurology, or in genetics it's  happening, but we don't know about this so we cannot  paint a broad brush and be able to say that this drug  or this other drug is bad or good. But we need to be  able to know whether our knowledge base is such that,  you know, we're not able to identify the right groups  of people who will be able to benefit from that. So we  have to distinguish all these different things. And, Steve, one thing that, you know, at  the beginning of the report we might consider sort of  putting together some of these overall thoughts and  define what we are talking about. And maybe even give  specific examples, as we have done in other reports, of  situations where, you know, a cognitive enhancement  approach, any of the ones that you talked about,  whether they are pharmaceutical, electrical, or  enhanced learning things, are wonderful, and where  something like that has not been so great. And so that  would sort of, you know, put everything into relief as to what is really important.

DR. GUTMANN: And where there's fear and concern and we have so little knowledge base that we  need more knowledge base there. Good. Dan.

DR. SULMASY: Thanks. I think this has  all been –

DR. GUTMANN: I have Dan, John, Christine.

DR. SULMASY: I think this has all been  very helpful. I'm just a little concerned about the  ambiguity in the phrase of per se permissible. I'm not  sure that it captures exactly what we want to say or  has a danger being misinterpreted. So I think that  what we probably want to say is that not all forms of  enhancement are immoral, right? I think that's really  what we want to say. But I think we also want to avoid the sort  of common fallacy of the continuum which is very common  in this sort of enhancement debate, which is a version  of the Sorites problem. How many grains of sand make a  heap? Right? At some point it will be a heap, but  where do we draw that line? And I think we don't want to say or give  the impression that we are saying that, well, drinking coffee is okay, therefore implanting transhumanizing  brain chips in everybody's brains is okay as long as we  have equal access to them. I don't think that's what  we want to say. So I think we've got to be careful to sort  of point out that that fallacy is common while still  saying that, you know, there are certain forms of  enhancement that ought to be considered morally  permissible. And then we can focus on the kinds of  issues that I think are the really important ones that  I've heard, like the questions of whose choice is it to  be enhanced. Is it coercion, manipulation questions;  the short-term versus long-term questions; whether we  are bypassing the deep and broadly applicable  capacities to do the same thing; safety and  alternatives; the questions of unfair advantage and the  sort of arms race that can lead to when one person gets  access to this and the next person needs to in order to  just keep up. Questions of moral enhancement which  might be part of or considered sometimes part of the  enhancement, et cetera. So I think those are the real issues you  want to focus on. And just my concern is that the per  se permissible language can be misinterpreted I think  as the sort of fallacy of the continuum. And I want to make sure we avoid that in this discussion.

DR. GUTMANN: So I don't think we want to  say it so it suggests that the default is suspect. So  we can say enhancing cognition is not in itself  suspect. In itself, it's not suspect. And then you  have to ask questions about each kind. One of the things I liked about what Steve  said that we hadn't said before and I think -- nothing  has been said to disagree with it, so I just want to  make sure, is that it would be important, since we are  focusing, because it is neuroscience, on the issues  that have been out there about cognitive enhancement,  we not just focus on the cognitive enhancement but also  the other forms of neural enhancement. Because I think  an unintended side effect of focusing on this cognitive  enhancement is totally unintended, because the critics  have -- the side effect, I think, is that people think,  "Oh, that must be something a lot of people think is  good." And it makes cognitive enhancement seem more  attractive than some other forms of enhancing your  ability to control your motor skills, for example. So I just think it's an important -- it's  important, given we are talking about neuroscience, not  just to talk about –

DR. SULMASY: Yeah. Certainly I'd agree with broadening it. But the same sort of question of  the fallacy of the continuum applies to these other  kinds of enhancements, as well. So I just want to make  sure that we -- it's so common in the literature that I  really think it would be very valuable for us to  explicitly repudiate that.

DR. GUTMANN: Yes. Good. Good. Jim had a question.

DR. WAGNER: Actually, it was your question but I want to make sure that we actually talk  about this, Dan. To hear Amy say that enhancements in and of themselves are not immoral, nothing wrong with that,  and then to hear your -- you begin that same paragraph  by saying not all enhancements are immoral. We are  going have to come to a place, where are we jumping on  this –

DR. SULMASY: Maybe my sort of take-out  might be, if you want to put a positive spin on the way  I do it is, "Plenty of forms of cognitive enhancement  are morally innocent."

DR. GUTMANN: Good. That's fine. Just as long as we don't phrase it to make  the default it's suspect. Okay? And also, it falls into the fallacy of the term, is such a loaded term, we have to be careful of  it. Okay. John.

DR. ARRAS: Well, first, thank you for  framing the issues so beautifully. I have to do  something similar at 2:30 and now I've got serious  performance anxiety. But enough about me.

DR. GUTMANN: Some people may have some  off-label drugs for you.

DR. ARRAS: So I want to circle back on a  theme that Raju was articulating, making distinctions  between, you know, interventions that might bring  people up to something like normalcy versus  interventions that take people well beyond. So I think  that there's a need in this report for a fair amount of  conceptual clarification. Okay? So just the definition of enhancement is  one area that needs some serious work. Another is the  distinction between enhancement and treatment or  enhancement and therapy. I mean, there are a lot of  efforts to drive a clear wedge between those notions,  to try and develop a kind of value-free conception of  disease or health. But I have always suspected that  those are, you know, infiltrating various value  judgments at various points.   And the treatment/enhancement distinction  pops up I think in a lot of the enhancement literature.  So you have to be self-conscious about invoking those  kinds of distinctions and self-conscious about what  kind of implications they might have. Now, another just short point I wanted to make  with regard to Stephen's attempt to broaden the scope  of this. In the literature of enhancement, there's  been quite a bit of talk in the last couple of years  about moral enhancement. Okay? So not just cognitive,  but moral. And so it's not just, you know, motor  activities, it's not just cognitive. But it's actually  sort of attempting by whatever means to make us more  altruistic, less violent, whatever. Okay? And I think that that could be a theme  that could be tucked into this section. I think this  could be an interesting thing. I'm actually going to  be talking about this in my current seminar on  neuroscience and ethics in a couple of weeks. But I've  got to do that reading soon.

DR. GUTMANN: Thank you. Christine?

DR. GRADY: So thank you to Steve and  Anita. And if you wait long enough on the queue, your  opinions have already been expressed.   What I wanted to say was I think somewhat  similar to what John just said and also building on  Raju's comments. I think we -- one of the things we can  do -- Amy, you asked what can we do? One of the things  we can do is be very clear about what we mean by  "enhancement." Because there is a danger, I think, in  the sort of common understanding of what that means,  means sort of above normal or from normal better. And  I think if that's what we want to focus on, then we are  sort of suggesting in a sort of indirect way that all  of the very important work that some of these  modalities can be used for to maintain cognitive  function or restore cognitive function or behavior or  motor, whichever one we are going to focus on, are less  important or we already know more about them, or  something like that. And I don't think that's what we  want to convey.

DR. GUTMANN: I think Steve captured this  really well in his outline but -- and we're going to  have to be explicit about this. We do not want to  subscribe to, buy into, the most common aspect of the  literature which is there's this just clear distinction  between enhancing cognition above normal, and therapy  below normal. Now, we also don't want to suggest there's just some mindless continuum. And Steve outlined it in a way that  doesn't buy into that. I think we are going to have to  say up front, we are taking on this issue in order to  debunk some of the misunderstandings out there, that  are ethical misunderstandings as well as, if you will,  practical cognitive. They are cognitive/ethical. Let me put it this way: I think the term,  the way it is commonly used, is misleading. And it is  misleading in a way that is very unproductive of  thinking clearly about the ethics of it and what's good  and what's not so good. What's better and what's  worse. So I think we can do that. But to ignore the  topic because it is misleading would just leave it out  there the way it is.

DR. GRADY: I didn't mean we should ignore  it. I think, though, that we have to be cognizant of  the fact that the term has a loaded meaning.

DR. GUTMANN: That's what we should say,  then.

DR. GRADY: And we have to be really clear  about what we mean by it and what we're trying to say.  Because so many of the things, the recommendations that  I think Anita is suggesting, the more research, fair  access and things like that, are relevant to all of the above, sort of all the possible ways we can think about  what enhancement might mean, without having to get into  the quagmire of what is the line between treatment and  enhancement which I think is -- people have been  working on it for a long time and not solved.

DR. GUTMANN: And I think a big focus is  what Steve said, promoting and informing the public.  And that's a key challenge.

DR. GRADY: Can I just add one other sort  of minor thing? We've talked a lot about research to  investigate benefits, efficacy, risk, side effects,  those kinds of things. I think that is all really  important. The one thing I wondered about was cost  effectiveness, whether we should say anything about  that.

DR. GUTMANN: I don't know. Nita?

DR. FARAHANY: So first, thank you to both  Steve and Anita for highlighting this in a very useful  way to frame the conversation. I'm going to express my reservation again  about how much we can say meaningfully on this topic.  And I know that it's probably one of the better and  more fully debated topics in neuro ethics. And I would want for us to be very careful about thinking about  what can we, as a Commission, say that's different and  novel and useful at this level? To whom are we  directing those recommendations? And what's the  purpose of the recommendations? I think some of the things that Steve  outlined are useful and in accord with things that we  have said in the past that could be helpful. But let  me speak about some of the issues that have been raised  more specifically. So first I agree entirely that we should  broaden the scope, but I wouldn't even use the word  "enhancements" because the broad topic which we are  talking about are different forms of neuro  modification. And how you characterize things as neuro  modification really are -- could be enhancements, could  be diminishments. So one example is the use of something  like propranolol to try to decrease fear memories and  to do so as a way to prevent the development of PTSD in  trauma victims. That's a form of enhancement in that  they are less likely to develop PTSD. It is also a  form of diminishment in that they are selectively  diminishing certain memories, the end point to be  dampening certain memories.   There's social disinhibition, which is a  positive side effect of alcohol but it is certainly a  diminishment in some form rather than an enhancement in  every form. And so trying to draw the line between  what is enhancement versus what is therapy versus what  is diminishment versus what is modification, I think  they are pretty artificial lines and it's a debate that  has been had and one that I think we don't want to end  up using a term that has simply become a term of art  that doesn't capture the broader concerns that we have  been talking about here. So I would suggest we move  away from that, to begin with.

DR. GUTMANN: But to take you literally  means we shouldn't use the term. We have to use the  term. It is out there. We have to debunk the term,  deconstruct it, go beyond it. But part of our job --  in almost everything we are dealing with there's a  robust literature and so on. But part of our job and our charge is to  say something about the ethics of neuroscience research  and its use. And I think in keeping everything --  consistent to everything you said is that we look at  the topic of cognitive enhancement and improve upon,  from our Commission's perspective, on the way it ought  to be discussed.   And everything you said after that, other  than we shouldn't use the term, is consistent with the  things we have been saying. I mean, we shouldn't buy  into the term but we need to recognize the way it's  used. It's like -- I mean, when we took on Craig  Venter's notion that he was creating life, we shouldn't  -- I mean, we took it on in order to say he wasn't  doing that.

DR. FARAHANY: So on this first point that  I want to make, I'm not suggesting that we don't make  reference to terms that people use in the literature.  I'm suggesting we not use that as our own framework for  the term as we discuss it. When we get to neuroscience  and law, for example, many people call it neuro law. I  have problems with people doing "neuro" words for  everything. So I think what I'm proposing is we don't  stay within the framework since the concerns that we  have addressed are much broader in scope; the motor  coordination ones and motor enhancements ones, moral  enhancement. Each of these, I think, would be much  more useful if we could start a new dialogue about the  broader issues that we are concerned about rather than  trying to stay within a label that has been self-defeating in many ways. The second issue is I want to endorse the  recommendation that Steve made about factcheck.org.  They say a broader -- and kind of the most valuable  thing I think that is consistent with what we have  proposed in past reports is this idea that information  forcing types of recommendations or information forcing  types of approaches are incredibly valuable. And  especially in this area, because there's a lot of  conflicting data out there about the value of brain  training games, about all sorts of different things. And people who are, in many cases,  desperate because they are noticing cognitive decline  or they're facing dementia or Alzheimer's or things  like that are investing a tremendous amount of money in  snake oil. So I think having something like  factcheck.org would be extremely valuable in empowering  people to make better choices about their use of  limited resources. On the distributive justice concerns, you  know, as we -- if we go the direction of neuro  modification -- and this will tie into the next issue  I'm going to talk about, the fallacy that Dan raises.  You know, this is true of every area. This isn't  something special or unique about neuro modification. Everything we do modifies our brain in some way and  modifies our brain in permanent ways. Simply being  here present today does so. Drinking tea, having  education, having good access to food, having  healthcare, all of these things have powerful effects  on our neuro state. And so the kind of answer of every new  opportunity to stop distributive justice appears to me  as kind of a hollow approach to policy-making. And I'm  not sure that saying that things like we should all  have equitable access to neuro modifications is either  meaningful or productive as a conversation in this  area. So talking about structural changes to try to  make sure everybody has access to it, it's far more  complex than that. Just this one example. Some of the  studies on modafinil show that people who are at the  lower end of the bell curve enjoy greater improvement  in cognition than people who are at the higher end.  And so what would equitable access in that context  mean, given that there's a differential effect and how  much improvement you can expect from any particular  thing? So I think I would recommend we stay away  from kind of empty rhetoric in that area.   On the fallacy point that Dan raises, I  think I disagree. And I disagree because I think there  are unique concerns that different modalities of neuro  modification raise. And those concerns for me are  primarily safety, efficacy, permanency. But they are  not really about naturalness or authenticity or things  like that. Because again, I believe everything we do  changes our brain in some ways. And the idea that there's something  suspect about a brain implant and not suspect about  caffeine to me is more about social norms of what we  have embraced and become comfortable with rather than  being particularly concerned of anything at any other  end of the continuum. So I don't think it's false that  we recognize these things as continuum. I think it's accurate to say that one of  the problems that has stymied the debate and  conversation in this area is the fact that it's so hard  to draw a line anywhere along what is a continuum, since  everything, in fact, does enhance the brain. And so I -- that's part of what persuades  me that this isn't as big of an issue is the things  that we have already come to accept that weren't  previously accepted are on the same continuum of trying  to improve human flourishing. And in this area which is so different than other areas, from my perspective,  enhancement or modification is about flourishing. The last thing I want to talk about is a  potential issue on regulation and ways to -- a specific  type of recommendation that we might contemplate. One problem in areas of improvement of  health or prevention or overall kind of enhancing drugs  or devices is that the traditional mode of regulation  looks at risks and benefits but it's very difficult to  quantify the benefit to any particular individual of a  modification that improves them over their existing  status. So our existing regulatory models, which  were designed for therapeutic purposes but not for  beneficial purposes, limit the ability of different  drugs and products to get to the marketplace, which to  me as bigger problem of access than any of the more  traditional structural problems of access in this  domain. And so trying to evaluate and come up with  a new model of how we might approve and get to market  in a safe and efficacious way, these different drugs,  recognizing that "benefit" may need a new meaning in  this context, I think could be a valuable and pretty  concrete thing forward.  

DR. GUTMANN: Barbara. And then we are  going wrap up this session and go to the next, because  time is limited.

DR. SULMASY: Quick response since I  was –

DR. GUTMANN: Really quick.

DR. SULMASY: Just to say that I'm not  sure that we disagree, actually. All I'm suggesting  what's fallacious is to conclude, from the fact that  there is a continuum, that therefore everything is  morally permissible along the continuum. I think that  you might want to make -- all you have to do is make an  argument for a particular place along the continuum.  That's what the fallacy is, that you can't  automatically –

DR. KUCHERLAPATI: But we have to agree  there is a continuum.

DR. SULMASY: Yes.

DR. KUCHERLAPATI: We have to draw a line,  but you can't say there's no continuum.

DR. SULMASY: No, no, absolutely.

DR. GUTMANN: I'm sorry. I'm working on  an old timeline here. So I now have the new timeline.  Great. Okay. Barbara.  

DR. ATKINSON: I've been interested in the  research questions that you would ask around this. And  it's not a simple area to be doing research in. I  think mostly because a lot of scientists wouldn't agree  that some of the ways off-label that these drugs are  being used or being proposed are worthwhile for  scientific research studies or clinical trials. And so  maybe have been -- and maybe would have trouble even  passing a human subjects committee in some of these  kinds of areas if you tried to propose studies looking  at how college students might use multiple drugs or  things like that. But I think that one of the things that  might be useful is to actually do comparisons with the  ordinary sleeping and exercise and diet kinds of things  as opposed to drug use and actually finding some data  on whether there really is an enhancement over and  above. Not just comparing it to nothing, but comparing  it to things that are simple things that can be done  that can be useful for everybody and everybody has  access to.

DR. GUTMANN: So Steve raised the  question -- Steve began, I thought, very -- the whole  thing was extremely useful, Steve and Anita, so thank  you both.   It begins with a whole range of examples  of what people often refer to when they are referring  to cognitive enhancement and then goes on - and this is  where I think we are in heated agreement - then goes on  to say we need to broaden this to the range of ways the  human nervous system can be enhanced. And also Nita  and Dan agree that there is a continuum of ways;  doesn't mean because there's a continuum all are  equally, you know, good or bad or efficacious or not  efficacious. In fact, we know they are not. Right? So that's very helpful. And I think we  can really run with that and broaden the understanding  and the debate. I think one of the most important  aspects of this report is what Steve said, promoting an  informed public. And I think we should run with that. Now, Steve, you asked a question and I'd  like to open it up for you, how you would answer it and  how anyone on the Commission would answer it. Is there anything in this area -- so we  said there's nothing -- enhancing cognition is not, in  itself, suspect and there's a range of dealing with  cognition, improving it. And if you improve cognition,  you could be doing it therapeutically or you can be  doing it where it's -- no doctor is going to prescribe  it, but you make your cognition better either in a given instance or overall than it would otherwise be. But here's the question: Is there an  equivalent in this area to human cloning? That's what  you asked. And there are all these -- is it the human  Cyborg? Which isn't the equivalent of cloning because  when cloning came about there was a clone of a sheep  named Dolly. And that raised the real question. So I'm just throwing that out, first, for  Steve. Is there some -- let me tone it down a bit. If  not an equivalent, what is the analogy here to human  cloning, and to what extent is it equivalent?

DR. HAUSER: Well, if I knew that answer I  would have framed it in a declarative way rather than  as a question. I again would go back to the beginning of  some of our deliberations where we -- in fact, where we  lead in our first volume, that there is nothing unique  about these questions that we are asking in the  neurosciences, but in some aspects they come into  sharper focus. And the concept of making an individual's  genome permanent, the human cloning concept is  certainly beyond the bell curve and something that is  formally prohibited. So what if we were to begin with  the possibility that neuro modulation -- and one could argue whether this is enhancement or not. But  presumably the purpose of it is that the function and  the ability to live in your environment is enhanced by  the manipulation. So even if it is decreasing the role  of an attribute that is unhealthy for that goal, it  would potentially be functionally enhancement. So what if we were to say, off the cuff,  that manipulations that are not permanent or are not  transferred to progeny are more reasonable than  manipulations that become a permanent external entity?  I guess the equivalent might be, in genetics, where --  what about gene therapy? Is gene therapy that enhances  a genome different from a cassette that does not get  integrated in the genome?

DR. GUTMANN: Yeah. Could I go in a  totally different direction? Because I don't think --  I think the distinction between enhance -- the  distinction between improving the working of the human  mind such that it's in some way permanent versus  temporary or some way -- I don't think there's a  good/bad here. So in the literature and in the debate out  there, the closest equivalent I can find to human  cloning, and it isn't -- is in the cognition sphere,  and that is the debate over whether you can create a computer that thinks just like a human being. In other  words, whether it is possible to have -- and if it  were, you know, whether it's possible to create an  entity that is just like a human being because it  thinks just like a human being. And there's a robust  debate –

DR. WAGNER: Huge literature.

DR. GUTMANN: -- about that. And I don't think -- you know, there's  no -- it turns out that turing -- there's a turing test  and it hasn't been passed. But there's a robust debate  that even if you could pass the turing test, it would  still be the equivalent of a human being. And it's a  very esoteric -- you know, I don't -- it's an esoteric  debate, it's a really important philosophical debate, it has real  practical import because it has to do whether -- with  just what you said, Steve, whether other aspects of  human thinking, which have to do with emotions and  control over behavior and the ability to express one's  self in a way that is not -- that is part of our  consciousness, is important. But there is a big literature out there  and a lot of concern that in our age of thinking about  how to manipulate the mind, we are forgetting what the  difference is between a machine and a human being. And that overlaps with the Dolly debate. Okay. So I think it's important to put it  out there because it's really part of the -- it's going  to be part of the debate moving forward.

DR. ALLEN: Just to follow up on the  things that we're frightened of. So the Dolly debate  analog could be the machine that has the capacity of  human cognition. But the other, I think, scary line  that we may not want to cross is where you have a human  being who has been manipulated such that they no longer  experience negative emotions or regret, sadness; their  painful memories, as Nita mentioned, are dispelled. I think we would -- to me that's a Dolly  moment when it's possible to do that, and we are  tempted to do it. And it may be that it's not a  drumline change, it's a change in one person. But the  idea of human beings who are just like us except they  are not burdened by pain, regret, sadness, et cetera,  that, to me, is something of ethical import and it is  even perhaps more imaginable than the brain that has  the human capacity.

DR. KUCHERLAPATI: I'm trying to think of  answering Steve's question. I can't think of any,  actually. And even this issue about the cloning and so  on and so forth, that's a social construct in the present society, right?

DR. GUTMANN: Right.

DR. KUCHERLAPATI: That's not considered  to be important. It happens all the time.

DR. GUTMANN: Social constructs are  important.

DR. KUCHERLAPATI: No, I understand. But  social constructs can also change, and they do change.  You know, in terms of cloning, for example, identical  twins, this is the nature's way of cloning. That's  exactly what happens. So I'm not sure of absolutes. If you consider in this neuro area, for  example, right, people with schizophrenia were sort of  put into cold -- ice cold water baths, right? That was  considered to be okay. If you asked me today, I would  say absolutely that's inappropriate. Or doing frontal  lobotomy would be considered to be okay forty years  ago. It would not be considered to be okay today. So I think things change so that I don't  think there's any absolute thing that you'd be able to  say in terms of this particular subject that should be  considered to be absolutely morally wrong. DR. GUTMANN: So my moral philosopher has  to say we are speaking as the Bioethics Commission  today. The fact that -- and you said you think this is absolutely wrong with regard to lobotomy. We have to  say what we believe today. That's the same thing with  science. The evidence changes. We don't know what a  hundred years from now scientific evidence will tell  us, but we have to do the best we can today.

DR. KUCHERLAPATI: But I guess the  distinction that we have to make is that so therefore  there is no absolute. That's what I'm saying. Because  when science changes, our social constructs will also  change, so that actually says there is not an absolute  thing.

DR. GUTMANN: We don't have -- that  depends on what you mean by "absolute." It is  absolutely wrong to commit genocide. And there are  other absolutes, too, in the sense that we know them as  well as we can know anything. And there is no -- we  can't imagine a human world in which that would not be  the case. There are a lot of things that we could  imagine changing, I just think that –

DR. KUCHERLAPATI: Just a lot of thinking  about that. In my own simple-minded way of thinking  about that is that, you know, killing would be  considered to be absolutely immoral. But clearly there  are circumstances under which killing is considered to  be okay or even approved. So that's what I am saying. The context is important but there is probably no  absolute.

DR. GUTMANN: Nita.

DR. FARAHANY: I think that the long-term,  short-term, or the future generation issue actually  reveals to us a different issue rather than it being  the issue itself. So I think thinking about the harm  to others and the harms to future generations is  important. I mean, one debate that happens quite a  bit in the enhancement debate is libertarian principles  versus paternalistic principles; self-autonomy,  decisions that a person can make for themselves versus  the harm it causes to others. So to both Steve's point and Anita's  point, I'm not troubled by a single individual who, for  example, suffers a rape being offered the option of  taking propranolol to dampen their fear memories and to  decrease their risk of developing PTSD. But I would be  troubled with an entire society having in-the-water  propranalol after 911 so that our social construct and  understanding of what happened and our fear and  inhibitions about things would occur. So I think what the long-term and  short-term issues, and whether or not there are certain things that are off limits, has a little bit more to do  with who is making the choice. Are we imposing the  choice on another person? Are we given the choice?  And what are the consequences to the choice we might be  able to make on others? And so I think the harm principle in  libertarianism is a useful limitation in this context  to understand what are the social consequences of  individuals being able to do neuro modifications. And  if those are grave, then we need to be concerned about  them. So for future generations, if there was  something neuro modification-wise that would pose some  sort of risk to future generations then I would be  concerned about it. I'm not aware of anything in that  context yet. But something similar would be, I'm  concerned about the use or the imposition of drugs or  devices on children where we don't understand what the  long-term implications are. So thinking about doing increasing  activation in one area of the brain which might come at  a consequence of a different area of the brain. So you  have a child who's very good at some particular  function but loses some other function over time. We  do that anyway with reading and other types of functions, but as we think about more direct brain  interventions, I think understanding who the actor is  and who gets to make the choice and what the social  consequences are is, to me, the bigger issue, the  consequence of which and some of the dimensions of  which may be long-term, short-term, whether or not  there's fear memories or other types of memories  modified.

DR. GUTMANN: Good. I think that builds  on this. I have Jim and then Dan.

DR. WAGNER: You know, I have listened  almost entirely to this, and I'm actually troubled by  the direction of the conversation and the scope of the  conversation. And correct me, please, if I'm wrong. I  think much of what we have been talking about is in  some ways -- and I'll try to support this, some ways  out of character for how we have discussed other issues  and I think perhaps even beyond the scope. The scope  that we have been asked to address, right, is the  direction of research for the brain project.

DR. GUTMANN: No. Actually, the scope is  that, plus the use of neuroscience more generally in  society. It's very much that.  

DR. WAGNER: Let's make sure that's right,  Amy. Because I'm concerned -- when I say out of  character, we have drifted into a realm that I  associate with something that we addressed before and  actually discharged, and that was the precautionary  principle that says one shouldn't even consider doing  research in areas that could lead to applications that  we can imagine being detrimental, right? I think we have a lot to contribute. And  I hope, even if I'm wrong and we should be talking so  heavily about applications, speculative and  demonstrably possible, even if I'm wrong and we should  be talking about those things, there is another rich  conversation that we need to have in this area about  where the knowledge gaps are that can help us ethically  inform future uses. And in the past, our character has been to  say that we don't find the pursuit of knowledge immoral  in and of itself. In fact, we have assumed it's amoral  to pursue knowledge. And if we don't have a  conversation -- and shame on us if we don't have a  conversation also about what we think the gaps are that  may or may not -- excuse me, they are not currently  being addressed in the research directions in which we  are going.   And I'm concerned that we have jumped  ahead in a very seductive conversation and set of  conversations that may keep us from fulfilling if not  the principle charge, which I had assumed, but if it's  not the principle charge it's at least an important  component of our charge of how we guide research, and  what the ethical questions would be in neuroscience  research and technology.

DR. GUTMANN: I think that what set this  off is the question of is there something like Dolly.  And it was not meant –

DR. WAGNER: No, it's not.

DR. GUTMANN: Oh, no. Okay. So –

DR. WAGNER: Go ahead.

DR. GUTMANN: No, I don't want to go ahead  because I want to figure out what set it off because I  think that for sure our charge is broader than  neuroscience research. And in fact, if it isn't  broader then we are pretty much done with our  deliberations because the first report pretty much said  what needed to be said there, with the exception of  some more specific things that we will say about  neuroscience research. But it is part of our charge, and also I  think really incumbent on us as a Bioethics Commission to try to clarify for the sake of public education,  which I dare say is our best hope here now, what some  of the misunderstandings are out there and what are  some of the potential, consistent with our principles.  So I –

DR. WAGNER: I hear you and I appreciate  the correction. If that's the case, then let's be  really confident also that cognitive enhancement,  consent issues, and intersections of law and  neuroscience are the three big categories and that --  we build -- we explain why it is that we are not going  to talk about other categories. For example, the  greatest uses presumably, which will be therapeutic  uses, that -- we don't have a fourth category and  probably can think of five or six. I had understood these three to be  wonderful vehicles to help explore some of the key  ethical questions about how it is we want to go about  getting the kind of knowledge that would impact not  just these three but more broadly. So I understood  these as vehicles rather than we think these are the  key applications that we need to understand.

DR. GUTMANN: So let me try to clarify  what I think we can do here. First of all, they're not the key applications.

DR. WAGNER: I agree.

DR. GUTMANN: So we are not picking them  because they are the key applications. And they are  only part of our report. They are three cauldrons of  controversy, if you will, which we can help shed light  on and clarify. Some of them will -- all of them will  have potentials for more research. We have already  uncovered one here, which is what are the actual uses  and risks and benefits in the way Nita - we should be  clear - broadened the category of all of these  cognitive enhancers and also really changed the way we  think about that. But to get to your central point, this  isn't all of what we have deliberated about or what we  will discuss in the report. We are also going to  discuss the important positive research areas that are  not necessarily, and often aren't, the most  controversial.

DR. WAGNER: Good. And I, again,  appreciate the clarification. I do -- and correct me  on this. The BRAIN project, though, as far as I know,  all of the dollars now up to what, $300 million, are  being made available -- wasn't there just an  announcement a couple weeks ago that the BRAIN was up to $300 million? Are being made available for  research. And so guiding how those $300 million go in  an ethical way, I think is a role that I understood to  be the key role that we are being asked to play.

DR. GUTMANN: I wish we had the power to  guide the way. We will recommend.

DR. WAGNER: Well, I meant recommend. You  know that.

DR. GUTMANN: But we will recommend, and  that is important. But if that's all we do, we are  writing a report to a group of funders who may or may  not take our suggestions, may or may not even, you  know, be -- and that's not -- and the reason it's  really important that we deliberate about this now is  that we need and we owe it publicly to have the  deliberation about this, as well as our  recommendations, which -- some of which we have already  made and we will make some more about funding. I'm going to keep John -- John's next on  the list. Dan? Sorry. You're right. Dan is next  on the list.

DR. SULMASY: First, I actually am  enjoying this conversation because I think that it is  within our scope and I think that it's one of these issues that is controversial enough that we actually  disagree with each other on certain parts of it, which  is actually good for deliberation, and may be helpful  because we can have this kind of conversation. And in the interest of trying to move it  forward, I have been struck by Nita's question about,  you know, is the term "enhancement" the wrong one. And maybe to sort of help clarify things,  maybe we need to come up with some other better  covering term. And one that comes to mind for me that  might cover all of what Steve said, for instance, would  be something like "functional neurological  improvements," which would cover both therapy from less  than two standard deviations below the mean into the  normal range, but could cover these things that are  beyond that, as well, which are typically what some  people mean by "enhancements." It could cover motor  things, et cetera. And part of what we could do is say this  is what we're talking about. And within this -- under  this covering term there's a range of different  interventions, modalities, that might be undertaken,  some of which raise different ethical questions than  others. And that's maybe a better way to frame the  conversation and the argument. Maybe there's a better -- this is not my area. Maybe there's a better  term already out there in the literature. But if there  isn't, something like this might be good.

DR. GUTMANN: John.

DR. ARRAS: Just a codicil to this  conversation. I mean, I think that kind of linguistic  substitution might work in a lot of cases, but I don't  think it would work in the case of memory attenuation.  That's not an improvement of memory. It's a kind of  disabling of memory. But anyway –

DR. SULMASY: We could talk about a  functional improvement by diminishment just as we treat  anxiety, we decrease a certain pathology. These are  considered improvement by decreasing certain –

DR. ARRAS: Improvement in terms of  quality of life, yeah. Okay. A couple of small points, mostly  for staff writing these reports up. One is I want to  state my agreement with Nita on the question of  long-term versus short-term. But just for those who are writing this  up, there is a very robust literature out there on the  ethics of, say, germline therapy versus somatic cell  therapy. I can tell you firsthand from a rather  unpleasant exchange that I had with George Annas -- actually, Elizabeth Fenton and I engaged in a debate  with Annas on just that question. And people like  Annas and Fukuyama are very clear that this is -- talk  about Dolly moments. I mean, that -- they would say  that any tinkering with the germline or anything that  is going to be extended into future generations is  really bad because it is going to undermine human  nature.

DR. GUTMANN: That's important because we  have talked about that in the synthetic biology and it  is not the line you –

DR. ARRAS: Yeah.

DR. GUTMANN: That actually is the less  science fictiony -- it's not science fiction at all.

DR. ARRAS: No.

DR. GUTMANN: The answer to the question I  threw out, and we have a position on that. And it's  not that something that will make a difference down the  line is inherently suspect.

DR. ARRAS: Yeah. Now, Amy, if you want a  science fiction analog to Dolly –

DR. GUTMANN: No.

DR. ARRAS: -- I will give it to you, and  that's the transhumanist manifesto, right?

DR. GUTMANN: Yeah. But I don't want it.  

DR. ARRAS: Nick Bostrom. Okay. I'm just trying to be helpful here.

DR. GUTMANN: Thanks. Steve and then Nita.

DR. HAUSER: I would just like to say two  things in response to Jim's comments which were, I  think, very helpful to me. And the first is maybe -- the first is the  concept about using neuroscience for therapy, which is  so important. And the question is, is it obvious? And  that's why we are focusing on enhancement. And just to go back for the younger people  in the audience, the original Congressional charter to  the NIH was not to carry out outstanding science but to  relieve suffering and to extend the lifespan of healthy  living, of healthy existence. And I think everything that -- or most  things that I can imagine that neuroscience would  contribute to relieving suffering, and someone with  schizophrenia or someone with a clear disease would be  front and center aligned with the original charge.

DR. GUTMANN: Yes.

DR. HAUSER: Now, the first question that  we have discussed this morning, where is that boundary.  And I think that -- we don't -- nobody has answers. But if we could frame that in a useful way for public  debate, that would be really, I think, important for  us. And then the second point that Jim made  about the BRAIN Initiative specifically -- and this is  a question to the Commission. The BRAIN Initiative is  magnificent for its goals but it is not all  neuroscience. It is a limited sector of neuroscience.  It does not include many, for example, of the  therapeutic opportunities that are at short hand for  some of these terrible diseases. And there is concern  that Walter Koroshetz raised, that others raised, that  the focus on the BRAIN Initiative could actually  decrease our momentum in some other areas. So the second question is, is this a  statement that somehow we think is important enough to  be in the report?

DR. GUTMANN: Yeah. We can talk about  that some more. But I think it's a very compelling  suggestion that you have. It is noon and we need to adjourn for  lunch and we will come back. And since Steve began it,  I think we will let him for now have the last word. But I do want to thank Steve and Anita for  really getting us off to an excellent start. So thank you very, very much. And we will reconvene at one o'clock.

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