Drug-Induced Impulse Control Disorders: A Prospectus for Neuroethical Analysis

Neuromodulation and memory: exploring ethical ramifications in memory modification treatment via implantable neurotechnologies

Invasive implantable neurotechnologies capable of simultaneously altering and recording neural activity are no longer the exclusive province of science fiction but a looming reality that will revolutionize medical practice. These advancements, particularly in their memory-altering capabilities, herald a vast array of opportunities for addressing the complex landscape of neurodegenerative and psychiatric conditions linked to memory impairments. However, the panoply of ethical implications arising from such a novel neurotechnology remains relatively unexplored by the neuroethics literature. This study examines and contrasts the potential ethical implications of memory modification treatment via implantable neurotechnologies. The study contends that undesired side effects resulting from memory modulation can lead to significant identity harms, disrupting the coherence of self-narratives and impinging on our authenticity. To evince the practical impact of this moral argument, the study conducts a practical ethical assessment of how employing implantable neurotechnologies to modulate memory may jeopardize (i) our moral responsiveness to events and core system of values and (ii) the emotional component associated with the altered memory. From a first-person standpoint, changes to the way we reasonably feel and react to past events and future intentions may be deemed ethically problematic as these profound changes can yield significant moral disruptions and negatively impact our personal lives and interpersonal relationships. In addition, the study discusses further ethical conundrums from a third-person perspective as these disruptions can inhibit social activism against structural injustices, thereby hindering societal progress. Thus, taking into account this societal dimension is paramount when evaluating the ethical permissibility of memory modification procedures.

Capacity, control and responsibility in Parkinson's disease patients with impulse control disorders: Views of neurological and psychiatric experts

Dopamine replacement therapy can induce impulse control disorders (ICDs) (e.g., hypersexuality) in susceptible Parkinson's disease patients. ICDs can sometimes result in criminal offending. In a number of past Commonwealth cases, it appears offending ICD patients have been considered to be suffering from 'irresistible impulses' such that their decision-making capacity, behavioural control and responsibility were totally compromised. This contrasts with courts' general scepticism of drug-induced 'compulsion' in cases of addiction-related offending. In one case of explicit ICD-related offending, testimony was limited to three experts and not contested by the prosecution. We explored whether the testimony offered in this particular case, and another similar case, reflects the views of the neurological and psychiatric communities at large. Thematic analysis revealed that neurologists, geriatricians and psychiatrists (n = 11): (a) attributed ICDs to a variety of causes; (b) considered ICD patients' decision-making capacities and behavioural control to be partially, but not totally, compromised; (c) were divided or ambivalent about ICD patients' responsibility; and (d) astutely noted the difficulties inherent in assessing complex constructs such as 'control' and 'responsibility'. We suggest that there is sufficient divergence between our findings and expert testimony from past cases for prosecution teams to engage their own experts in future cases of ICD-related offending.

Moral Enhancement, Self-Governance, and Resistance

John Harris recently argued that the moral bioenhancement proposed by Persson and Savulescu can damage moral agency by depriving recipients of their freedom to fall (freedom to make wrongful choices) and therefore should not be pursued. The link Harris makes between moral agency and the freedom to fall, however, implies that all forms of moral enhancement that aim to make the enhancement recipients less likely to "fall," including moral education, are detrimental to moral agency. In this article, I present a new moral agency-based critique against the moral bioenhancement program envisaged by Persson and Savulescu. I argue that the irresistible influences exerted by the bioenhancement program harm our capabilities for conducting accurate self-reflection and forming decisions that truly express our will, subsequently undermining our moral agency.

Rethinking responsibility in offenders with acquired paedophilia: punishment or treatment?

This article reviews the current neurobiological literature on the aetiology of developmental and acquired paedophilia and examines what the consequences could be in terms of responsibility and treatment for the latter. Addressing the question of responsibility and punishment of offenders with acquired paedophilia from a neurobiological perspective is controversial. Consequently it is essential to avoid hasty conclusions based strictly on neurobiological abnormality justifications. This study establishes a distinction between developmental and acquired paedophilia. The article investigates whether offenders who fulfil the diagnosis of acquired paedophilia should be held fully responsible, particularly in cases where the offender's conduct appears to result from volitionally controlled behaviour that is seemingly incompatible with a neurological cause. Moreover, the article explores how responsibility can be compromised when offenders with acquired paedophilia have (partially) preserved moral knowledge despite their sexual disorder. The article then examines the option of offering mandatory treatment as an alternative to imprisonment for offenders with acquired paedophilia. Furthermore, the article addresses the ethical issues related to offering any form of quasi-coercive treatment as a condition of release. This study concludes that decisions to fully or partially excuse an individual who fulfil the diagnosis of acquired paedophilia should take all relevant information into account, both neurobiological and other environmental evidence, and should proceed on a careful case by case analysis before sentencing or offering treatment.

When benefitting a patient increases the risk for harm for third persons - the case of treating pedophilic Parkinsonian patients with deep brain stimulation

This paper investigates the question whether it is ethically justified to treat Parkinsonian patients with known or suspected pedophilia with deep brain stimulation - given increasing evidence that this treatment might cause impulse control disorders, disinhibition, and hypersexuality. This specific question is not as exotic as it looks at a first glance. First, the same issue is raised for all other types of sexual orientation or behavior which imply a high risk for harming other persons, e.g. sexual sadism. Second, there are also several (psychotropic) drugs as well as legal and illegal leisure drugs which bear severe risks for other persons. We show that Beauchamp and Childress' biomedical ethics fails to derive a veto against medical interventions which produce risks for third persons by making the patients dangerous to others. Therefore, our case discussion reveals a blind spot of the ethics of principles. Although the first intuition might be to forbid the application of deep brain stimulation to pedophilic patients, we argue against such a simple way out, since in some patients the reduction of dopaminergic drugs allowed by deep brain stimulation of the nucleus subthalamicus improves impulsive control disorders, including hypersexuality. Therefore, we propose a strategy consisting of three steps: (1) risk assessment, (2) shared decision-making, and (3) risk management and safeguards.

Authenticity or autonomy? When deep brain stimulation causes a dilemma

While deep brain stimulation (DBS) for patients with Parkinson's disease has typically raised ethical questions about autonomy, accountability and personal identity, recent research indicates that we need to begin taking into account issues surrounding the patients' feelings of authenticity and alienation as well. In order to bring out the relevance of this dimension to ethical considerations of DBS, I analyse a recent case study of a Dutch patient who, as a result of DBS, faced a dilemma between autonomy and authenticity. This case study is meant to point out the normatively meaningful tension patients under DBS experience between authenticity and autonomy.

Nonmotor symptoms in Parkinson's disease in 2012: relevant clinical aspects

Nonmotor symptoms (NMSs) of Parkinson's disease (PD) are common, but they are often underrecognized in clinical practice, because of the lack of spontaneous complaints by the patients, and partly because of the absence of systematic questioning by the consulting physician. However, valid specific instruments for identification and assessment of these symptoms are available in 2012. The administration of the self-completed screening tool, NMSQuest, associated with questioning during the consultation, improves the diagnosis of NMSs. NMSs play a large role in degradation of quality of life. More relevant NMSs are described in this review, mood disorders, impulse control disorders, cognitive deficits, hallucinations, pain, sleep disorders, and dysautonomia.