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ORIGINAL PAPER
Is There a Need for Clinical Neuroskepticism?
Eran Klein
Received: 2 June 2010 /Accepted: 4 August 2010
#
Springer Science+Business Media B.V. 2010
Abstract
Clinical neuroethics and neuroskepticism arerecententrantstothevocabularyofneuroethics.Clinicalneuroethics has been used to distinguish problems of clinical relevance arising from developments in brainscience from problems arising in neuroscience research proper. Neuroskepticism has been proposed as a counterweight to claims about the value and likelyimplications of developments in neuroscience. Thesetwo emergent streams of thought intersect within the practice of neurology. Neurologists face many tradition-al problems in bioethics, like end of life care in the persistent vegetative state, determination of capacity in progressive dementia, and requests for assisted suicidein cognition-preserving neurodegenerative disease (likeamyotrophic lateral sclerosis). Neurologists also look to beattheforefrontofdownstreamclinicalapplicationsof neuroscience, like pharmacological enhancement of mental life. At the same time, the practice of neurology,concerned primarily with the structure, function, andtreatment of the nervous system, has historicallyfostered a kind of skeptical attitude toward its ownsubject matter. Not all problems that appear primarilyneurological are primarily neurological. This disciplin-ary skepticism is generally clinical in orientation andlimited in scope. The rise of interest in clinical neuro-ethics and in neuroskepticsim generally suggests a possible broader application. The clinical skepticism of neurology provides impetus for thinking about theappropriate role for skepticism in clinical areas of neuroethics. After a brief review of neuroskepticismand clinical neuroethics, a taxonomy of clinical neuro-skepticism is offered and reasons why a stronger rather than weaker form of clinical neuroskepticism is current-ly warranted.
Keywords
Neuroethics. Neuroskepticism. Neurology.Clinicalethics.Clinicalneuroethics. NeuroscienceJust to amuse myself, and keep the good people busy, I ordered them to build this City, and my palace; and they did it all willingly and well.Then I thought, as the country was so green and beautiful, I would call it the Emerald City, andto make the name fit better I put greenspectacles on all the people, so that everythingthey saw was green [1].
Introduction
A neurologist can be said to see the world through brain-tinted spectacles. An older man walking down
NeuroethicsDOI 10.1007/s12152-010-9089-xE. Klein (
*
)Department of Neurology, L226,Oregon Health and Sciences University,3181 SW Sam Jackson Park Road,Portland, OR 97239, USAe-mail: eran.klein.neurology@gmail.com
the street with asymmetric armswing. Parkinson
’
sdisease? Awoman interviewed on the local news withmonotonous speech. Right hemisphere dysfunction?A new colleague at work with a crooked smile. Adistant stroke? A clinic patient
’
s episodes of blurryvision, headache, and fatigue. A new case of giant cellarteritis? It is a peculiar skill to come to see othersthrough the functioning (or dysfunctioning) of thenervous system. Yet it is, arguably, the quintessentialskill of a neurologist to encounter others in this way, a skill that often, though not always, pays dividends.This peculiar skill is incubated typically within a rather brain-centric domain of medicine. Neurologistslearn to be neurologists surrounded by basic neuro-scientists, neuroradiologists, neurosurgeons, neuro- psychologists, psychiatrists, and others withspecialized knowledge of the brain. Immersed withinthis environment, the donning of brain-tinted spec-tacles becomes second nature.
“
Of course one
must
think of such and such a neurologic diagnosis first when presented with
those
symptoms.
”
Clinicaleducation transitions the neurologist-in-training fromabstract study of the nervous system (the
“
ology
”
of the
“
neuro
”
) to a practical prioritization of the brain indiagnosis and treatment: think brain first. Over time,the neurologist
’
s spectacles can become rather affixed.The skill of the neurologist runs aground, however,if not traveling alongside a healthy skepticism, what Dewey called the mark and pose of the educated mind[2]. Medicine is replete with neurological mimics.That which appears primarily neurological, some-times - in fact often - is not. An old shoulder injurycan account for asymmetric armswing, personality or disinterest for reduced prosody of speech, a childhoodadmiration of Harrison Ford for a rye smile, and theneed for new glasses and more sleep for the triad of blurry vision, headache, and fatigue. A single-focused pursuit of a neurologic cause of symptoms, when a primary non-neurologic cause is more apt, can bemisleading and sometimes costly. The ability todistinguish between that which
looks
primarily neu-rological and that which
is
primarily neurological, if not part of the neurologist
’
s peculiar skill, is requisiteto its proper use.Bioethics is currently enamoured of ethical problems related to states and conditions of thenervous system (much of which currently runsunder the label of
“
neuroethics
”
)[3,4]. For a
neurologist with spectacles firmly and unabashedlyattached, this neurophilia may seem perfectly
a propos
.
1
Developments in neuroscience, broadlyunderstood, are having and will continue to haveimportant ethical implications that deserve attention.Many of these implications, still largely underappre-ciated, will be felt in and around clinical medicine, particularly neurology. But such neurophilia alsoraises concern. A tendency to cast an increasingnumber of problems in bioethics as
“
neuro
”
prob-lems may lead, as it does analogously in clinicalmedicine, to distortion. Not all ethical problems that involve the brain are necessarily best approached interms of the brain.Some form of neuroskepticism is needed in bioethics. The challenge is to arrive at an appropriatekind. The aim of what follows is to explore thisquestion along a narrow, but practically relevant dimension: clinical bioethics. Clinical ethics problemsinvolving pathological conditions of the nervoussystem represent a domain ripe for annexation bythe
“
neuro.
”
–
9]. After a brief discussion of what is meant generally by neuro-skepticism and by clinical neuroethics, a notion of
clinical
neuroskepticism will be proposed. I argue that clinical neuroskepticism can take different forms andthat these forms can usefully be mapped onto viewsof different strengths
—
weak, moderate, and strong.A review of these different forms of skepticismsuggests that a stronger rather than weaker form of clinical neuroskepticism is currently warranted. Thisexercise and its conclusion, though ostensiblyconcerned with clinical bioethics, may have implica-tions for those interested in neuroscience and ethicsmore generally.
Typology of Neuroskeptism
The last decade has seen a proliferation of
neuro-logisms
“
neuro
”
prefix across disparate intellectual domains hasoccurred absent a clear articulation of what makesactivities distinctly
“
neuro
”
in any non-trivial sense,
1
Though Trout
’
s recent introduction of the term
neurophilia
as well as absent a due appreciation of existingdisciplines from which these
“
new
”
neuro activitiesarise [14]. The emergence of
neuroskepticism
as yet another entry in this linguistic
neurofication
of discourse (a sin of which I am now wholly guilty) ishardly surprising.
2
Along with the proliferation of
“
neuro
”
terms comes the need for linguistic resourcessuited to critique of this proliferation and the activitiesso named. Neuroskepticism is the most obviousmember in what might be viewed as a family of
“
neuro
”
critical terms. No consensus definition of neuroskepticism hasyet to emerge. Jonathan Marks has recently sug-gested the term to mean
“
a perspective informed byscience studies scholarship that views with somehealthy skepticism claims about the practical impli-cations and real-world applications of recent devel-opments in neuroscience [16].
”
This definitionkeenly locates the target of skepticism at the levelof individual
claims
. Popular culture and academicliterature are increasingly punctuated by claimsabout what
“
neuroscience is now able to do.
”
Notwithstanding the many benefits that recent work in neuroscience has afforded human understandingand human health, neuroscience has lent itself, perhaps more so than other sciences, to presentationin terms of individual claims shorn of context,scientific and otherwise. A
claims
neuroskepticismis perhaps the most obvious form of neuroskepti-cism.
3
Neuroskepticism can take as its target more
systematic
features of neuroscience as well. Thegenerative systemic features can be of different types: disciplinary, evidentiary, or methodological.
4
Skepticism can arise as to disciplinary boundarieswithin neuroscience or within areas of inquiry about neuroscience. Particular domains in neuroscience, or how their boundaries are drawn, have raised skepticalconcerns. For example, skepticism of mental illnessand professional activities surrounding it (e.g., devel-opment of diagnostic categories and methods of treatment) has long been a challenge faced by psychiatry [17]. Skepticism also has arisen about the boundaries of inquiry
about
neuroscience. The most obvious of these is given voice in recent debates over whether neuroethics warrants status as an independent field or discipline (rather than, say, a subsidiary or dependent area of interest extending across existingfields) [18,19]. Can the
boundaries
delimiting non-scientific concerns about neuroscience (e.g., neuro-ethics, neurolaw, neuroeconomics, etc.) that havegrown up of late bear critical scrutiny? Is there a conceptual coherence underlying these newly mintedactivities or would they come apart or meld together if pragmatic pressures (e.g., popular interest in the brainor proximity to substantial neuroscience funding)were removed?Categories of argument or evidence commonlyadduced in neuroscience generate skeptical worry of a different sort. Various forms of inference made on the basis of emerging neurotechnology (most notablyfunctional MRI) about thought patterns, personality,or moral sensibilities, provide recent examples of this.Doubt as to whether certain
kinds
of inference can bemade from functional imaging data has attended thiswork since its inception [20]. Skepticism about the proper use of images, narratives and metaphors tomotivate normative concerns about neuroscience isanother related form of systemic worry. The apparent illumination purchased by turning to popular linguis-tic resources (e.g.,
“
neuroscientific narratives
”
and
“
neuroscientific imaginaries
”
2
The recent penchant for attaching favored prefixes (
“
neuro
”
)to familiar terms is not a practice to which those of a neuroscience bent are more prone. One sees the proliferationof neologisms, for instance
“
geneticization,
”
3
It is important not to conflate a skeptical approach toneuroscientific claims to a rejection or refutation of suchclaims. Good science and cogent argument are the ultimatearbiter of the merit of individual claims. A skeptical approach,rather, is a demand for attention to the level of rigor inevaluating such claims. At minimum, skepticism requires that claims of interest (here, claims about the implications of neuroscience) receive equitable evaluation. Claims of interest should be subject to no less rigorous evaluation than is found inrelevantly similar cognate domains. A skeptical approach,arguably, also may require
higher
levels of scrutiny or evidenceat times, such as when the context in which claims are madeand evaluated subverts reasonable evaluation (e.g., the unique psychological
“
pull
”
of brain imaging).
4
Types of systemic neuroskepticism identified here
—
disci- plinary, evidentiary, methodological
—
are not wholly separa- ble. Disciplines are understood, at least in part, in terms of their standards of evidence or the methodological tools they employ.And methods are inextricably bound up with the forms of evidence to which they are suited. Nonetheless, there is somevalue
—
and at least prima facie plausibility
—
to separatingthese out and treating them as separate targets of skepticism.Is There a Need for Clinical Neuroskepticism?
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